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Aik STATE ID NUMBER 90000014332005 CONTAINER CONSTRUCTION E. ( ) '01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( D 04 PHENOLIC LINING ( D OS CLASS LINING (X) 07 UNLINED ( ) OB UNKNOWN t D 09 OTHER: F. ( ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION :( ) 04 UNKNOWN (X) 05 NONE' E ) `06 TAR OR ASPHALT' t D 09 OTHER VI PIPING A. ABOVEGROUND PIPING:: t ) 01 DOUBLE-WALLED PIPE ( } 02 CONCRETE-LINED TRENCH ( ) 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 BOXES) ( ) 04 PRESSURE 05 SUCTION f ) 06 UNKNOWN ( ) 0 ) E VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( D 07 PRESSURE TEST ' ( D 09 NONE t ) ,10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU ARE NOT RE4UIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED D 01 ( ) 02 t ) 03 ( ) 01 ( ) 02 ( ) 03 ( 3 01 f D 02 ( ) 03 f J 01 ( l 02 ( ) 03 D 01 ( J 02 ( ) 03 ( D 01 ( J 02 ( ) 03 ( l 01 O 02 O 03 t D 01 ( J 02 ( ) 03 f ) 01 E l 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( :) 01 YES (X) 02 NO THIS FOR H' J BEEN C TED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF :MY KNOWLEDGE: IS TRUE AND CORRECT. FSLING (SI A E) HONE / D FOR LOCAL: AGENCY USE ONLY ADMINISTRAUNG AGENCY , CITY CODE COUNTY CODE CONTACT PERSONPHONE W/AREA CODE DATE OF LAST INSPECTION JIN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ) 02 N0 HSC04-070185 (10/18/85) PAGE 2