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AML STATE 10 NUMBER $004,45793200S CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED' t ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING t ) 05 GLASS LINT. ( ) 07 UNLINED (X) 08 UNKNOWN t 1 09 OTHER. F. ( ) 01 POLYETHLENE WRAP t l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN f ) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE E ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY ('CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE B. U14DERGROUND PIPING'• ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE t ) 05 SUCTION t 2 06 UNKNOWN t ) 07 NONE VII LEAK DETECTION iX 03 VISUAL ( ) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 ;GROt WATER MONITORING WELLS ( ) 07PRESSURETEST t ) 09 NONE E ) 10 OTHER VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIREO TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STORED ( ) 01 ( ) 02 ( ) 03 Ol E ) 02 ( ) 03 OI ( ) 02 ' ( ) 03 ( ) 01 t ) 02 f ) 03 ( ) 01 t ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 { 1 03 01 f ) 02 ( ) 03 ( ) 01 ( ) 02 t ) 03 ( ) 01 ( ) 02 ( ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t ) 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 FILING (SIGNATURE)'/,/- PHPNE W1 REA CO FOR LO-CAL AGENCY USE ONL ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PrPS� N' PHONE W/AREA DATE OF 'LAST INSPECTION TIN COMPLIANCE - PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2