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STATE ID NUMBER 00000054749004 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING f 1 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) OS NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 103 GRAVITY (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE S. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE f 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION f 1 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS f ) 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 APE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED (X) O1 ( ) 02 ( 1 03 INDUSTRIAL SEWAGE WASTE ( ) 01 ( ) 02 ( 1 03 ( 1 Ol ( 1 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( 1 02 ( ) 03 1 ) Ol ( ) 02 ( ) 03 ( l O1 ( 102 ( ) 03 f 1 01 ( 1 02 ( ) 03 f ) Ol ( ) 02 ( ) 03 ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED UN ER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (SIONATUR PHONE W/ARCA CODE FOR LOCAL AGENCY US ONLY ADMINISTRATING AGENCY CITY CODE COVNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # ( ) O1 YES f 1 02 NO )SC04-070185 (10/18/85) PAGE 2