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STATE ID NUMBER 00000002205002 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( )' 02 ALKYD LINING ( ) 03 EPDXY LINING t l 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN. ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP t l 02 VINYL WRAPPING ( ? 03 CATHODIC PROTECTION (X) 04 UNKNOWN t ) 05 NONE ( ) 06 TAR OR ASPHALT t T 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: t ) 01 DOUBLE—WALLED PIPE ( 1 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (,,�) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: { 1 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION t ) 06 UNKNOWN t ) 07 NONE VII LEAK DETECTION 01 VISUAL t l 02 STOCK INVENTORY 1 ) 04 VAPOR SNIFF WELLS t l 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS t ) 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDE+RGROUND` CONTAIN,ERS IF YOU CHECKED YES TO IV-F YOU ARE NOT REPUTRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS#t (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAMED STORED STORED ( ) 01 ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 ( D 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 t D 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTA%NER LOCATED ON AN AGRICULTURAL FARM? ( l 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANDa TO THE BEST OF MY KNOWLEDGEa IS TRUE AND CORRECT. pER NG (S G AT ) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF -LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID #R ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2