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STATE IO NUMBER 00000065248002 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY'LININGt ) 04 PHENOLIC LINING 05 GLASS LINING ( ) 07 UNLINED ( ) 08 UNKNOWN (X) 09 OTHER: - F. ( B 01 POLYETHLENE WRAP ( D 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION { 8 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT { ) 09 OTHER: VI PIPING A. ABOVEGR PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( _) 05 SUCTION t ) 06 UNKNOWN ( Y 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE X(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY 00 04 VAPOR SNIFF WELLS (X) 05 SENSOR INSTRUMENT (X) 06 GROUND WATER MONITORING WELLS ) 07 PRESSURE TEST ( )`09 NONE ( l 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 ( ) 01 ( ) 02 ( ) 03 t ) O1 ( ) 02 ( ) 03 ( 101 ( ) 02 ( ) 03 t ) Ol ( ) 02 ( ) 03 ( ) 01 ( ) 02 t ) 03 t ) 01 ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f D 01 YES (X) 02 NO THIS FORM HAS BEN COMPLETED UNDER THE PENALTY OF PERJURY AND9 TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILIN I URED PHON W/AREA CODE FOR LOCAL AGENCY USE ONLY ADM ISTRAT NG AGENCY ® 1 CITY CODE COUNWOE CONT l P RSO r `�, PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # 1,7 01 YES t ) 02 NO NSC04-070185 (05/05/86) PAGE 2