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STATE ID NUMBER 00000014332007 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING t' ) 03 EPDXY LINING t ) 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED,,,. ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02VINYLWRAPPING f ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN t ) 05 NONE (X) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: E ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION t ), 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: t ) ;01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( l 07 NONE VII LEAK DETECTION { ) 01 VISUAL (X) 02 STOCK INVENTORY { ') 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT t ) 06 GROUND WATER MONITORING WELLS t ) 07 PRESSURE TEST ( ) 09 NONE { l 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 PREVIOUSLYDELETE CA$# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED (X) 01 ( ) 02 ( ) 03 MOTOR OIL ( ) 01 t 1 02 ( ) 03 t D 01 t ) 02 ( ) 03 t l 01 I ) 02 It ) 03 ( ) 01 ( ) 02 E ') 03 { ) 01 ( ) 02 { ) 03 ( ) 01 ( ) 02 [ ) 03 { ) 01 ( ) 02 t ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 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 AS BEEN COMP UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. P PSON FILING (SIGNAT' ) �HE W/ REA CODE c' FOR LOCAL AGENCY USE ONLY ADMINISTRAUNa AGENCY t ICITY CODE COUNTY CODE CONTAC PEPSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL GATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ) 02 N0 HSC04-070185 (10/18/85) PAGE 2