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STATE ID NUMBER 000000316400`05 CONTAINER CONSTRUCTION E. ( ) 07 RUBBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING t ) 04 PHENOLIC LINING t ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER F. ( ) 01 'POLYETHLENE WRAP t ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( } 04 UNKNOWN t ) 05 NONE (X) "06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( J 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOM ES) ( ) 04 PRESSURE ( 3 05 SUCTION t J 06 UNKNOWN L>r 07 NONE B. UNDERGROUND PIPING- ( D 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (M 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL 2 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS ( D 05 SENSOR INSTRUMENT 06 GROUND WATER MONITORING WELLS 07 PRESSURE TESD' t l 09 NONE t ) 10 OTHER: VIII CHEMICAL. COMPOS`ITION 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 ( ) 01 ( ) 02 t ) 03 ( ) 01 ( ) 02 ( ) '03 ( ) 01 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 ( ) 01- ( ) 02 ( D 03 ( ) 01 ( ) 02 ( ) 03 { ) 01 ( ) 02 t ) 03 E ) 01 ( ) 02 ( D 03 ( ) 01 ( ) 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t ) 01 YES 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE: IS TRUE AND CORRECT. PEPS5P FILING (SIGN RE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCYp CITY CODE COUNTY CODE { Q c - CONTACT PERSON U PHONE W/AREA CODE LOCAL PERMIT ID # DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION RATE ,,, ( ) 01 YES ( Y 02 NO r HSC04-070185 (10/18/85) PAGE 2