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STATE ID NUMBER 00000021915002 CONTAINER CONSTRUCTION E. ( ) O1 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 00 OTHER= 01 POLYETHLENE WRAP i ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE i ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) f ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION t 1 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION ( 1 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS [ ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( ) 09 NONE t ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS iF YOU CY.ECk;ED YES TO IV-F YOU APE NOT REQUIRED TO CCMPLETE THIS SECTION CURRENTLY PPEVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) STORED STORED ( ) 01 t ) 02 ( 1 03 ( ) 01 ( 1 02 ( 1 03 ( ) 01 ( l 02 ( l 03 ( ) 01 t 1 02 f ) 03 ( ) 01 ( 1 02 ( ) 03 ( ) 01 f ) 02 t ) (13 ( 1 01 t ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 O 01 ( 1 02 ( l 03 I I I D ( 1 01 t ) 02 ( 1 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS LIS CONTAINER. LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PEPSON 'FILING (SIGNATURE) � ( PHONE W/ARE COOS c 4 � � -6C FOR LOCAL AGENCY USE ONLY ADMINISTRATIN3 AGENCY c CITY C001 COUNTY CODE C.11 CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOGAL PERMIT ID # i ) O1 YES ( ) 92 NO PAGE 2 HSC04-070185 (10/18/85)