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STATE 20 NUMBER 00000010942003 CONTAINER CONSTRUCTION E. ( . 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING [ ] 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( J 02 VINYL WRAPPING l ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( J 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 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) (X) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN l 1 07 NONE VII LEAK DETECTION (X) 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-P YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STCRED STORED ( ) 01 ( 1 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 (. ) 01 ( ) 02 ( ) 03 ( ) 01 ( 1 02 { ) 03 1 ) 01 ( l 02 ( ) 03 ( ) 01 ( J 02 ( J 03 ( ) 01 ( ) 02 ( ) 03 [ ) 01 ( 7 02 ( ) 03 ( 1 O1 ( 1 02 ( ) 03 ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 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. PERSON FTLIND (SIGNSTURE)/ /�/� PHONE W/AREA CODE` tl ' 0/ / � � � ,11L/ /c FOR LOCAL AGEN4' USEONLY— - //�� ADMINISTRATING AGENCY 10151 CITY CODE COUNTY CODE .541V C'- /4a Al CONTACT PERSON PHONE W/AREA CODE 7 LSc AP F --- --- DATE OF pLAST /I SPECTION IN GOMPLIANC! PERMIT APPROVAL DATE TRANSACYSON-PA" - LOCAL PERMIT ID Y ( ) O1,YES f ) 02 NO HSC04-070185 (10/18/85) PAGE 2