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STATE ID NUMBER 00000036602001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER F. ( ) 01 POLYETHLENE WRAP f d 02 VINYL WRAPPING f d 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE 05 TAR OR ASPHALT ( d 09 OTHER: VI: PIPING A. ABOVEGROUND PIPING': ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( 105 SUCTION (X) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (:CHECK APPROPRIATE BOX(ES) (X)" 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN 4 ) 07 NONE VII LEAK DETECTION (X) 01 VISUAL (X) 02 STOCK INVENTORY t l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR 'INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 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 Fs PPENTLY PREVIOUSLY DELETE CAS# CIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) TORED STORED t 3 01 ( ) 02 ( ) 03 ( d 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 It ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 { ) Ol ( ) 02 ( ) 03 (, ) 01 ( ) 02 ( ) 03 ( ) 01 t ) 02 ( d 03 ( ) 01 C ) 02 It ) 03 { ) 01 f ) 02 t ) 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 CSZGNATURE) PHONE W/AREA CODE n/l 4,;,L- FOR LOCAL. AGENCY USE ONLY ADMINTSTPATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHON! W/AREA CODE DAY! OF LAST INSPECTION IN COMPLIANCE AERMIT APPROVAL DATE TRANSACTION DATELOCAL PERMIT ID ## > .� Eir C ) Q2 YES ( ) 02 NO HSC04-030185 (10/18/85) PAGE 2