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0 0 STATE ID NUMBER 00000037196001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 7 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER- F, ( 7 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f ] 03 CATHODIC PROTECTION ( 7 04 UNKNOWN ( 1 05 NONE (X) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING- ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 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 ( 7 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL ( 1 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT f ) 06 GROUND WATER MONITORING WELLS f 1 07 PRESSURE TEST (X) 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) CHEMICAL (DO NOT USE COMMERCIAL NAME1 STORED STORED ( ) 01 ( 7 02 ( ) 03 ( ) 01 ( ) 02 ( l 03 ( 1 01 ( ) 02 ( ) 03 ( ) 01 ( 7 02 ( ) 03 ( ] 01 C ) 02 ( ) 03 p ( ) 01 ( Y 02 ( ) 03 01 ( 1 02 ( ) 03 ( 1 01 f 7 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( 7 01 ( . l 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS ISCONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 001 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. PERSON FILING (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ) 02 NO PAGE 2 HSC04-070185 (10/18/85) Yt Penalties will be added after due date as shown: 30 days - 100% of Base Fee