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STATE ID NUMBER 00000024100044 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYO LINING; ( 9 03 EPDXY LINING t 1 04 PHENOLIC LINING ( D 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( D 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER VI- PIPING A. ABOVEGROUND PIPING: ( ) 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 BOX(ES) ( ) 04 PRESSURE f ) 05 SUCTION ( ) 06 UNKNOWN (X) 07 NONE VII LEAK DETECTION t l 01 VISUAL (X) 02 STOCK INVENTORY ( ) 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-R YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STOPED l 01 ( ) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 01 ( ) 02 ( ) ;03 C ) 01 ( ) 02 ( ) 03 f l 01 ( ) 02 ( ) 03 t ) 01 ( ) 02 f ) 03 d t 01 ( ) 02 ( ) 03 ( D 01 ( ) 02 ( D 03 01 ( ) 02 t ) 03 i ) 01 ( ) 02 ( D 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO L_ 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 ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE' DATE OF LAST INSPECTION IN COMPLIANCE PERM%T APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ) 02 NO HSC04-070185 (20/18/85) PAGE 2