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STATE ID NUMBER 00000001276005 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION { 1 04 UNKNOWN ( l 05 NONE (X) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE C ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: t ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN t ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS E ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS (X) 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 (00 NOT USE COMMERCIAL NAME) STORED STOPED 01 ( ) 0.2 ( ),03 ( J 01 ( ) 02 ( ) 03 f ? 01 ( l 02 ( ) 03 { ) 01 ( ) 02 ( ) 03 t ) Ol ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 01 t ) 02 ( ) '03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS I5'CONFAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X-1 02 NO THIS FOPM HAS BEEN COMPLETED UNDER T E PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGEs IS TRUE AND CORRECT. PERSONL ( GNAT U ) PHO E W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATI '" AGENCY CITY CODE COUNTY CODE !:&& A. 13,7 CON ACT PERSON PHO E W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2