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STATE ID NUMBER 00000014332001 CONTAINER CONSTRUCTION E. t ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( D 04 PHENOLIC LINING t ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN 4 ) 09 OTHER F. t ) 01 POLYETHLENE WRAP t D 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE (X) 06 TAR OR ASPHALT 4 ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE t 7 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) f ).04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( .-) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( i 06 UNKNOWN t ) 07 NONE VII LEAK DETECTION ( l 01 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT 06 GROUND WATER MONITORING WELLS { l 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CH'E'CKED YES TO IV-F YOU ARE NOT REQUIRED TO 'COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED { ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 ( i 01 ( ) 02 ( ) 03 101 ( ) 02 t- ) 03 ( ) 01 ( ) 02 ( ) 03 f ) 01 ( ) 02 C ) 03 l 01 ( ) 02 C ) 03 i ) 0,1 ( ) 02 f ) 03 t ) 01 ( ) 02 ( ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( D 01 YES (X) 02 NO THIS FORM HAS EEN COMP ETED PENALTY OF PERJURY ANDS TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PaSC7N NG (SIGN P PHONE W/AREA CODE FOR LOCAL A ENCY USE ONLY ADMIN TR.4TING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PH E W/AREA CODE LOCAL PERMIT ID # DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE t ) 01 YES` ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2