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i CONTAINER CONSTRUCTION STATE ID NUMBER 00000009396003 E. ( 1 O1 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( 1 O1 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION (X1 04 UFIKNOWN ( ) 05 NONE f 1 06 TAR OR ASPHALT ( 7 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( 7 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE S. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (CHECK APPROPRIATE BOX ( ) 03 GRAVITY BOX(ES) (X1 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) STORED STORED CHEMICAL (DO NOT USE COMMERCIAL NAME) ( ) Ol ( 1 02 ( 1 03 ( 1 01 ( 7 02 ( 3 03 ( ) O1 ( ) 02 ( 1 03 ( 1 01 ( 7 02 ( ) 03 [ ) Ol ( ) 02 ( )- 03 ( ) Ol ( ) 02 ( ) 03 ( l 01 ( 1 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 f 7 O1 ( 1 02 ( 1 03 ( ) O1 ( 1 02 ( ) 03 • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED UNDER NA LTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (SIGN R ) _ PH NE W/AR A CODE NN°°� 31 - 373'8 FOR LOCAL A Cy USE ONLY ADMINISTRATIry3� AGENCY CIT CODE COUNTY CODE CONTACT PER O�INSPECT PHONE W/AREA C DE Zt 131 - 3?3"8 ;DATE OF LAST N IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE ( ) O1 YES f 1 02 NO LOCAL PERMIT ID # HSC04-070185 (10/18/85) PAGE 2