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STATE ID NUMBER 00000001198004 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING f D 03 EPDXY LINING t ) 04 PHENOLIC LINING f 105 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE { ,3 06 TAR OR ASPHALT t ) 09 OTHER= VI PIPING A. ABOVEGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE C ) 02 CONCRETE-;LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXtES) ( ) 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) t ) 04 PRESSURE ( ) 05 SUCTION t ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS E ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS t D 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: 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 CA$# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STOPED ( ) 01 ( r 02 ( ) 03 L(Q ( ) o>1 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 ( 01 ( ) 02 ( ) 03 t ) o2 ( ) 02 ( ) 03 ( ') 01 ( ) 02 ( ) 03 t l 01 (-) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 01 ( ) 02 ( :) 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 FI=LING (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COJNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE P RMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # 02 NO HSC04-070185 (10/18/85) PAGE 2