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STATE ID NUMBER 00000005761002 CONTAINER CONSTRUCTION E. S ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING 4 1 04 PHENOLIC LINING S 1 05 GLASS LINING 4 ) 07 UNLINED (X) 08 UNKNOWN f ) 09 OTHER- F. f 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING I ) 03 CATHODIC: PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f J 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) ( ) 04 PRESSURE (X) 05 SUCTION ( J 06 UNKNOWN C ) 07 NONE VII LEAK DETECTION ( l 01 VISUAL (X) 02 STOCK INVENTORY ! ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT t ) 06 GROUND WATER MONITORING WELLS t 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS P YOU CHECKED YES TO IV-F YOU ARE NOT RECUIRED TO COMPLETE THIS SECTION CUPPENTLY PREV:CUSLY DELETE CAS« (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) STCREO STOPED ( ) 01 ( ) 02 ( ) 03 1 t j I I I I I I C, ( ) 01 ( 02 ( ) 03 ( ) Ol ( ) 02 t )_03 ( l 01 t ) 02 ( ) 03 ( ) 01 ( ) 02 t 1 03 jj ( ) 01 ( 1 02 ( ) 03 { ) 01 ( 1 02 ( ) 03 I ) 01 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 f ) 01 ( ) 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS LIS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO THIS FOR ' HAS B EN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON NG (SIGNATURE) PHONE W/AREA CODE FOR AOC AGENCY USE ONLY ADM I ST LCY 15� CITY CODE COUNTY CODE CONTACT(PFR)ON PHONE W/AREA CODE S-P�p_ 1 C DATE OF LAST INSFECT:CN IN COMPLIANCE PERMIT ,APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID -2 - 97- S ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2