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CONTAINER CONSTRUCTION STATE ID NUMBER -00000021610001 E. f ) O1 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING f01 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) CATHODIC PROTECTION ( 1 04 ( ) Ob TAR OR ASPHALT f ) 09 OTHER: 03 UNKNOWN (X) 05 NONE VI PIPING A- ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXES] f ) 04 PRESSURE f ) 05 SUCTION ( ) Ob UNKNOWN f ) 07 NONE B. UNDERGROUND PIPING: f 1 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY !CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) OS SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: II VI IF YOUCHCKED CHEMICAL-1 TO XV-p OMPOSITIE NOT R REQUIRED TO LS STORED IS SECTION IN UNDERGROUND CONTAINERS CURRENTLY PREVIOUSLY DELETE CAS# (IF KN STORED STKNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) ( ) O1 ( ) 02 ( ) 03 ( ) O1 f ) 02 ( ) 03 ( ) Ol f ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 f 1 Oi ( Y 02 ( 1 03 ( ) Ol ( l 02 ( ) 03 ( ) 01 ( ) 02 ( 1 03 ( ) O1 t ) 02 ( ) 03 ( ) Ol f ) 02 ( ) 03 ( ) 01 ( ) 02 ( 1 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS 5 CONTAINER LOCATED ON AN AGRICULTURAL FARM? (X) 01 YES ( ) 02 NO (S FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. 'RSON FILING (SIGNATURE) PHONE W/AREA CODE IR LOCAL AGENCY USE ONLY IINISTRATING AGENCY CITY CODE (TACT OEFSOW couNrr CODE PHONE W/gREA COD[ E OF LAST INSPECTION IN COMPLIANCE ( ) 01 YES ( ) 02 NO PERMIT APPROVAL DATE TRANSACTION GATE LOCAL PERMIT xo u 4-070185 (10/18/85) PAGE 2