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STATE ID NUMBER 00000012631002 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED: ( ) 02 ALKYD LINING ( ,) 03 EPDXY LINING ( l 04 PHENOLIC LINING t ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING t l 03 CATHODIC PROTECTION E ) 04 UNKNOWN (X) 05 NONE t- l 06 TAR OR ASPHALT d ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 41 DOUBLE—WALLED PIPE { 1 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE { ) 05 SUCTION ( ) 06 UNKNOWN t l 07 NONE S. UNDERGROUND PIPING: t ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXES) (X) 04 PRESSURE { ) 05 SUCTION ( 1 06 UNKNOWN { l 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( 3 04 VAPOR SNIFF WELLS t 1 05 :SENSOR INSTRUMENT t ) 06 GROUND WATER MONITORING WELLS E ) 07 PRESSURE TEST ( ) 09 NONE (X) 10 OTHER: LINE LEAK DETECTOR VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU ARE NOT' REQU%RED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (%F KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED ( ) 01 E ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 G ) 01 ( ) 02 ( ) 03 E ) 01 ( )< 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 f ) 01 ( ) 02 ( ) 03 t l 01 ( ) 02 ( ) 03 { ) 01 ( ) 02 ( ) 03 t ) 01 t ) 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 FOAM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON e%LNG (SIGNATU ) 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 COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2