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STATE ID NUMBER 00000054315002 CONTAINER CONSTRUCTION E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING f 1 04 PHENOLIC LINING ( 1 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION f 1 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT f 7 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f 7 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE S. UNDERGROUND PIPING: ( ) 01 ODUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION [ 1 06 UNKNOWN f ] 07 NONE VII LEAK DETECTION .f ) 01 VISUAL (X) 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS ( 7 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS [ l 07 PRESSURE TEST ( ) 09 NONE (X) 10 OTHER: PIPING-RED JACKET LE 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 PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STORED ( ) 01 ( ) 02 ( 1 03 ( ) 01 ( ) 02 - ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( 1 02 ( ) 03 ( ) el ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( 1 03 R 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, IS TRUE AND CORRECT. PERSON FILING (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/ARIA CODE DATE OF LAST INSPECTION IN COMPLIANC! PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT I0 # l 1 O1 YES f 1 02 NO HSC04-070185 (10/18/85) PAGE 2