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CONTAINER CONSTRUCTION STATE ID NUMBER 00000042163001 E. ( ) 01 RUEBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( l 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) (X) 06 TAR OR ASPHALT ( ) 09 OTHER OS N04E VI PIPING A. ABOVEGROUND PIPING ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY (CKECK APPROPRIATE BOXES) ! ) 04 PRESSURE ( ) 05 SUCTION f ) 06 UNKNOWN ( l 07 NONE B. UNDERGROUND PIPING ( l O1 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL2 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER= VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINER'S :F YOU CHECKED YES TO IV-F YOU APE NOT PEOUIPED TO COMPLETE THIS SECTION CURRENTLY PREVICUSLY DELETE CAS# (IF KNOWN) STCPED r CHEMICAL (DO NOT USE COMMERCIAL NAME) STOR_D O 01 O 02 O 03 I I I I I I I I ( l 01 O 02 O 03 ( ) 01 ( ) 02 ( ) 03 O 01 O 02 O 03 I I I I I I I I I I ( l 01 ( ) 02 ( ) 03 I ( l 01 ( ) 02 ( l 03 I I ( ) 01 ( ) 02 ( ) 03 O 01 O 02 ( l 03 I I f I I l l l l ( ) 01 ( ) 02 ( ) 03 I I I I I I I I II ( l 01 ( ) 02 ( ) 03 LI * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS :S CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO IS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. tcON F-L: (SIGNATURE) PHONE W/AREA CODE OR LOCAL AGENCY USE ONLY _..:N:S7PA7:NO AGEwCY CITY CODE COUNTY CODE INTACT PEONF , PHONE W/AREA CODE Ml x ATE OF LAST :NSPZCTION IN COMPLIANCE PERMIT APPPOVAL DATE TRANSACTION DATE LCCAL PEPMZT :D # ( ) 01 YES ( 7 02 NO :04-070185 (10/18/85) PAGE 2 r