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STATE ID NUMBER 00000015479003 CONTAINER CONSTRUCTION E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( l 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( l 05 NONE ( ) 06 TAR OR ASPHALT ( l 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( l 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING- ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXES) (X) 04 PRESSURE ( l 05 SUCTION ( ) 06 UNKNOWN t ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS (X) 05 SENSOR INSTRUMENT (X) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( 1 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOJ CHECKED YES TO IV-F YOU ARE NOT PEOUIF.ED TO COMPLETE THIS SECTION CUPPENTLY PREVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED ( l 01 ( l 02 ( l 03 ( ) 01 ( ) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 ( 1 O1 ( ) 02 ( ) 03 ( 1 01 ( l 02 ( l 03 ( 1 01 ( ) 02 ( ) 03 ( l 01 ( ) 02 ( l 03 ( ) 01 ( l 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( 1 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, IS TRUE AND CORRECT. (PERSON- IN . (SIGN RE) PH NE W/ PEA CODE - � p F ` LOCAL AGENCY USE ONLY ADMINISTPATING AGENCY CITY\ CODE COUNTY CODE I J :CVTACPERSON PHONE W/ARBADJ DATE OF LAST INSPECTICN IN COMPLIANCE FERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ) 02 NO HSCO=,-070185 (10/18/85) PAGE 2