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STATE ID NUMBER 00000051616001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED E D '02 ALKYD LINING ( 1 03 EPDXY LINING ( D 04 PHENOLIC LINING ( D 05 GLASS LINING t ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. t ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING t D 03 CATHODIC PROTECTION (X) 04 UNKNOWN t ) 05 NONE t ) 06 TAR OR ASPHALT : t ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH t ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE E ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. U).DERGROUNO PIPING: t D 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( D 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE tX) 05 SUCTION ( D 06 UNKNOWN t D 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT 06 'GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE t ) 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 ( H 01 ( ) 02 ( ) 03 ( D 01 ( ) 02 ( ) 03 ( D 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 D 01 ( ) 02 ( ) 03 ( ) 01 t ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 ( D 01 ( ) 02 ( ) 03 3' 01 ( ) 02 ( ) 03 - ( ) tai ( ) 02 ( ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t ) 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY Of PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (SIONATURE) PHONE W/AREA CODE FOR LOCAL Y US ONLY ADMI' ISTPATING AGENCY CITY CODE COUNTY CODE CONTA,CT PERSON PHONE W/A EA CODE DATE OF LAST INSPECTION IN COMPLIANCE J;;;M,IT APPROVAL GATE TRANSACTION DATE LOCAL PERMIT10 # ES ( ) 02 N0 HSC04-070185 (10/18/85) PAGE 2