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STATE ID NUMBER 00000009414001 CONTAINER CONSTR%UCTION E. ( D 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING ( l 04 PHENOLIC LINING ( l 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( D 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( 102 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( D 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER= VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( J 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE 91 05 SUCTION ( ) 06 UNKNOWN ( l 07 NONE VII LEAK DETECTION ( l 01 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS t l 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS C D 07 PRESSURE TEST ( ) 09 NONE t ) 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 CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STOPED STORED ( ) 01 ( ) 02 ( ) 03 ( J 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 101 ( ) 02 ( ) 03 ( ) 01 ( D 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 ( J 01 ( ) 02 ( ) 03 l DS ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 0-1 t ) 02 ( ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS:CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO I THIS FORM :HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILII3G (SIGNATURE) PH NE W/AREA CODE aa I 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 S ( ) 01 YES f ) 02 NO HSC04-070185 (10/18/85) PAGE 2