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STATE ID NUMBER 00000023498001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( l 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ) 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 ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (�j 04 PRESSURE ( ) 05 SUCTION +At 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( l 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE ( ) 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 CUPP.ENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STOPED STORED ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( l 02 ( ) 03 I ( ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( 1 O1 I ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( l 01 ( l 02 ( ) 03 t l 01 ( ) 02 ( ) 03 ( ) 01 t ) 02 t ) 03 :+ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS CS ::ONTAINER LOCATED ON AN AGRICULTURAL FARM?_,J-) 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE NAL TY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. 'PcRS (S AT/ PHONE W/AREA CODE ;OR LOCAL AG Y USE ONLY :;MINI TRATING-13ENCY CITY CODE COUNTY CODE PHONE W/AREA CODE CO)iT.CT PO-SQN DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ZD # ( ) 01 YES ( ) 02 NO PAGE 2 HSC04-070185 (10/18/85) L