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STATE ID NUMBER 00000051616003 CONTAINER CONSTRUCTION E. ) 01 RUBBER LINED t ) 02 ALKYD LINING t ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING t ) 05 GLASS LINING t ) 07 UNLINED (X) 08 UNKNOWN (':) 09 OTHER: F. (' ) 01 POLYETHLENE WRAP t ) 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN [ D 05 NONE ( ) 06 TAR OR ASPHALT t } 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: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( D 06 UNKNOWN ( ) 07 NONE VII-LEAK DETECTION t } 01 VISUAL (X) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS ( } 05 SENSOR INSTRUMENT t ) Oar 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 t l 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( D Ol ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 ( l 01 t ) 02 ( ) 03 ( 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 { ) 03 ( ) 01 t ) 02 t )'03 ( ) 01 ( ): 02 ( ) 03 ( `) 01 ( ) 02 ( ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PE ALTY OF PERJURY AND: TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PER ON FILING (S ATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 0 ( ) 01 YES ( T 02 NO HSC04-070185 (10/18/85) PAGE 2