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STATE ID NUMBER 00000001276006 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ] 03 EPDXY LINING ( i 04 PHENOLIC LINING E ) 05 GLASS LINING (X) -07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETMLENE WRAP ( l 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION t l 04 UNKNOWN ( ) 05 NONE (X) 06 TAR OR ASPHALT t J 09 OTHER VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY {CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING- ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE t l 05 SUCTION ( ) 06 UNKNOWN ( D 07 NONE VII LEAK DETECTION f l 01 VISUAL (X) 02 STOCK INVENTORY t l 04 VAPOR SNIFF WELLS { 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST f ) 09 NONE ( ) 10 OTHER: VIII CH-EMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU ARE NOT RE9UIREO TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STCPED ` t ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 E ) 01 ( ) 02 ( ) 03 { ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 t 3 01 ( ) 02 ( ) 03 { ) 01 ( ) 02 t ) 03 ( J 01 ( ) 02 ( ) 03 E ) 01 ( ) 02 t ) 03 { ? 01 ( ) 02 ( l 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO THIS FORM HM BEEN COMPLETED UNDER THE PENALTY Of PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. I. -S0N LSIGN UR ) PH W/AREA CODE r c FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE ..-- Ca L CON ACT PERSON P E W/AREA CODE L DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) O1 -YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2