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STATE ID NUMBER 00000000655004 CONTAINER CONSTRUCTION E. f 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( } 03 EPDXY LINING f ) 04 PHENOLIC LINING ( 1 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER= F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( 1 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( 1 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE B. UNDERGROUND PIPING: [ ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH C ) 03 GRAVITY (CHECK APPROPRIATE BOXCES) f ) 04 PRE55URE t } 05 SUCTION (X) 06 UNKNOWN ( } 07 NONE VII LEAK DETECTION `( ] Oi VISUAL ( 1 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS [ 1 07 PRESSURE TEST (X1 09 NONE f ] 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 CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STOPED STORED ( 1 01 ( ) 02 t 1 03 ( 1 01 ( 7 02 ( ) 03 ( ) 01 f 1 02 ( ) 03 [ d Ol ( ) 02 ( ) 03 ( ) 01 ( ] 02 f ) 03 i ( ) 01 ( 1 02 ( ) 03 ( 1 01 C 1 02 ( ) 03 E 1 01 ( i 02 ( ) 03 ( 1 01 ( ) 02 ( 1 03 ( ) al ( 1 02 ( 1 03 �( CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS FIS 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. 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 INS;ECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID #t ( ) 01 YES ( } 02 NO HSC04-070185 (10/13/851 PAGE 2