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STATE ID NUMBER 00000062251001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER 'LINED ( ) 012 ALKYD LINING; ( ) 03 EPDXY LINING ( a 04 PHENOLIC LINING f ) 05 GLASS LINING (X) 07 UH LINED ( ) OB UNKNOWN f a 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN E D 05 NONE t 1 06 TAR:OR A sP9A_LT J J 09 ;OTHER: VI PIPING A. ABOVEGROUND PIPING:_ ( ) 01 DOUBLE—WALLED PIPE t ,) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE OOXtES) ( )'04 PRESSURE ( ) 05 SUCTION ,( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING), t a 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK `APPROPRIATE BOM ES) 1 04 PRESSURE ( ) 05 SUCTION d ) 06 UNKNOWN ( l 07 'NONE VII LEAK DETECTION ( -) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT f ) 06 GROUND WATER MONITORING WELLS 00 07 PRESSURE TEST t ) 09 NONE ( D 10 OTHER VIII CHEMICAL COMPOS.ITI'ON 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 STORED ( ) 01 ( ) 02 ( ) 03 ( J 01 ( ) 02 t ) 03 t a 01 ( ) 02 ( ) 03 t 01 ( l 02 ( ) 03 ( ) 01 ( l 02 1 ) 03 l l 01 ( D' 02 ( ) 03 t D 01 ( l 02 ( ) 03 D 01 ( 1 02 ( ) 03 ( ) 01 f 1 02 ( ) 03 f 1 01 ( ) 02 ( ) 03: CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f J 01 YES (.X) 02 NO THIS FORM HAS SEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILI (SIGNATURE) � PHONE W/AREA CODE ®9 Al FOR LOCAL AGENCY USE ONLY ADMINISTRATING -AGANCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APP-ROVAL DATE TRANSACTION DATE LOCAL PERRiIT ID #) ( l OI YES ( ) 02 NO HSC04-070185 (10/18/B5) PAGE 2