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STATE ID NUMBER, 00000013501001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 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 ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( l 01 DOUBLE-WALLED PIPE ( l 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) ( 1 04 PRESSURE 00 05 SUCTION ( l 06 UNKNOWN ( l 07 NONE VII LEAK DETECTION 01 VISUAL (7L02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT l 06 GROUND-WATER MONITORING WELLS (Kl 07 PRESSURE TEST ( l 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 CURRENTLY PPEVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STOPED ( l 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( l 03 ( ) 01 ( ) 02 i ) 03 ( ) 01 ( ) 02 i 1 03 ( ) 01 ( ) 02 ( l 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( l 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 UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I/S' TRUE AND CORRECT. � ? = CV FILIN3 (SICNAT. l �.0 E�O" n > Y FOR L CAL A NCY USE ONL ADMINIa3TP.A11N3 AGEoke 0- .J�.�I � CITY CODE COUNTY CODE ADMINISTRATING r CONTACT PERSON PHONE W/AREA CODE Mt'k /e ' 30 9`/ - 9 DATE OF LAST INSPECTION �IN COMPLIANCE PERMIT .APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # 0 M1 YES ( ) 02 NO jj HSC04-070185 (10/18/85) �A PAGE 2