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STATE 10 NUMBER 00000014332003 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING 03 EPDXY LINING 04 PHENOLIC LINING 05 GLASS LINING (X) 07 UNLINED (X) 08 UNKNOWN 09 OTHER: F. ( ) 01 POLYETHLENE WRAP 02 VINYL WRAPPING 03 CATHODIC PROTECTION 04 UNKNOWN 05 NONE (X) 06 TAR OR ASPHALT 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: t ) 01 DOUBLE—WALLED PIPE 02 CONCRETE—LINED TRENCH t ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 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 C ) 0.5 SUCTION f l 06 UNKNOWN 07 NONE VII LEAK DETECTION 01 VISUAL (X) 02 STOCK INVENTORY 04 VAPOR SNIFF WELLS 05 SENSOR INSTRUMENT ) 0,6 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 CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED !STORED 01 ( ) 02 f ) 03 01 ( ) 02 ( ) 03 01 ( ) 02 1 ) 03 01 ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 ol ) 02 ( ) 03 01 ) 02 ( ) 03 01 f ) 02 ( ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t ) O1YES" (X) 02 NO THIS FORM H BEEN COMPLETE UNDE"E PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGEs IS TRUE AND CORRECT. PERSON I a (SIUPHONE W/AREA CODE A' �m x FOR LOC AJ?,A�ENC�YUSE�GNLY ADMINISTPATING APENCY CITY CODE COUNTY CODE !&& I I. CONTACT PERSON 0 PH W/ REA CODE fq- DATE OF LAST INSPECTION IN COMPLIANCE IPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 # ( ) 01 YES 02 NO HSC04-070185 (10/18/85) PAGE 2