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STATE ID NUMBER 00000031688002 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED t 1 02 ALKYD LINING ( 1 03 EPDXY LINING t 1 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN t ) 09 OTHER- F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT [ ) 09 OTHER- VI PIPING A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( 102 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 ( 1 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE t ) 05 SUCTION ( l 06 UNKNOWN t ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ] 05 SENSOR INSTRUMENT [ ) 06 GROUND WATER MONITORING WELLS ( 3 07 PRESSURE TEST ( ) 09 NONE (X) 10 OTHER: Q VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU ARE NOT REPUIRED TO COMPLETE THIS SECTION (CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) STOPED STORED ( ) 01 ( 1 02 1 1 03 I [ (( f ( ) 01 ( ) 02 ( ) 03 { [ I I I I I 3 [ ( ) al ( 1 02 ( ) 03 f ) 01 ( ) 02 ( 1 03 i l 01 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 [ ) 01 ( ) 02 ( ) 03 [ ) 01 ( ) 02 1 1 03 4 l 01 ( ) 02 ( ) 03 F ) 01 ( ) 02 t ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? i l 01 YES (X) 02 NO THIS FO A BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE: IS TRUE AND CORRECT. PEP N F I (S� TUP.E) PHONE W/AREA CODE :.'OR LOCAL AGE USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE S rigt,U l G CONTACT PERSON PHO/N�EfW/AREA CODE (DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID tt ( ) 01 YES ( ) 02 NO liSC04-070185 (10/18/85) PAGE 2