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STATE ID NUMBER 00000024100002' CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) .02 ALKYD LINING ( ) 03 EPDXY LINING F ) 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER= F. ( ) 01 POLYETHLENE WRAP ( } 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN t ) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER VI PIPING A. ABOVEGROUND PIPING= F ) 01 DOUBLE—WALLED PIPE t ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: F ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE F ) 05 SUCTION t D 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION t ) 01 VISUAL (X) 02 STOCK INVENTORY ( D 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 ; CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED ( d 01 ( ) 02 ( ) 03 01 ( ) 02 ( )-03 ( d 01 ( ) 02 ( `) 03 ( ) 01 ( ) 02 ( ) 03 ( ) o1 ( ) 02 ( ) 03 ( } 01 ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t l 01 YES (X) 02 N0 THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY A.DMINISTR.ATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTIONIN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2