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STATE ID NUMBER 00000054749001 CONTAINER CONSTRUCTION 1 ) 01 RUBBER LINED ( ) 02 ALKYD LINING l 1 03 EPDXY LINING f l 04 PHENOLIC LINING ( 1 05 GLASS LINING ( ) 07 UNLINED 1X1 08 UNKNOWN ( ) 09 OTHER: f ] 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN [ 1 05 NONE ( ] 06 TAR OR ASPHALT f 1 09 OTHER: I PIPING ABOVEGROUND PIPING: f 1 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION fX) 06 UNKNOWN ( ) 07 NONE . UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE i ) 05 SUCTION f ) 06 UNKNOWN ( ) 07 NONE II LEAK DETECTION f 1 01 VISUAL 1 ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS l 1 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: III CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU ARE NOT PEOUIPED TO COMPLETE THIS SECTION JRPENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STOPED 1 ) Ol ( ) 02 ( 1 03 ( 1 Ol ( ) 02 ( ) 03 I I I ( I Ol ( ) 02 ( ) 03 ( 1 O1 ( 102 ( ) 03 f ) 01 1 ) 02 ( ) 03 ( 1 Ol ( 1 02 ( ) 03 f l 01 f l 02 ( 1 03 ( 1 01 ( ) 02 ( ) 03 f 1 Ol ( ) 02 ( ) 03 ( 1 01 f ) 02 ( ) 03 + CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS S CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO IS FORM HAS BEEN COMPLETED UNZER THE PENAL Y OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. EPSON FILING (SIONATUP 1 PHONE W/APEA CODE OR E AN LOCAL AGENCY USE ONLY ,O MINISOCAL 0 AGENCY CITY cone COUNTY CODE :ONTACT PERSON PHONE W/AREA COD! )ATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DAT! LOCAL PERMIT IO 0 ( 1 01 YES ( ) 02 NO 3C04-070185 (10/18/85) PAGE 2