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J r STATE ID NUMBER 00000011073002 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( 1 02 ALKYD LINING t ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING ( 1 07 UNLINED (X) 08 UNKNOWN ( 1 09 OTHER: F. ( ) 01 FOLYETHLENE WRAP t ) 02 VINYL WRAPPING ( D 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( 1 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING* ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE V) 05 SUCTION ( ) 06 UNKNOWN ( l 07 NONE VII LEAK DETECTION (X) 01 VISUAL (X) 02 STOCK INVENTORY ( i 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT [ ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST f ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU A.PE NOT P.ECUIPEO TO COMPLETE THIS SECTION CJ'**?ENTL'r FPE;ZCUSLY CEIETE CASx (IF KNOWN) CHEMICAL (DO NOT USE COMMEPCIAL NAME ) ST02E0 STCPED ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 t l 03 ( ) 01 ( l 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( D 03 ( D 01 ( ) 02 ( ) 03 I ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS LI_SCONTAINER 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. ff FILIN3 (SIGNATURE) PHONE W!AREA CODE FOR LOCAL AGENCY USE ONLY AD`1INIS7P.ATING AGENCY CITY CODE COUNTY CODE CONTACT PEPSCN PHONE W/.APIA CCDE DOTE OF LAST INSPECTION IN COMPLIANCE PEPMZT APPPOVAL DATE TRANSACTION DAT? IGC AI PEPMIT ZO a HSC04-070185 (10/18/85) PAGE 2