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S STATE ID NUMBER 00000031640004 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING [ ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( l 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER. F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( T 04 UNKNOWN ( ) 05 NONE (X) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( + 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ) 05 SUCTION ( ) 06 UNKNOWN ( l 07 NONE VII LEAK DETECTION ( 101 VISUAL STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( l 06 GROUND WATER MONITORING WELLS07 PRESSURE TEST ( ) 09 NONE t l 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIP.ED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STOPED STORED ( ) 01 ( l 02 ( ) 03 ( ) 01 ( l 02 ( ) 03 ( ) 01 ( l 02 ( ) 03 ( ) 01 ( l 02 ( ) 03 f ) 01 ( ) 02 ( l 03 ( ) 01 ( 102 ( ) 03 ( ) 01 ( l 02 ( ) 03 ( ) 01 t ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( l 02 ( 1 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES 02 NO awn THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE) IS TRUE AND CORRECT. PERSON ILING (SIGNATU^ PHONE W/AREA CODE pp FOR LOCAL AGENCY USE ONLY ADMINISTPATLG AGENCY CITY CODE COUNTY CODE o a& La .0 s fir► 3 CONTACT PERSON PHONE W/AREA CODE .20 -9 VV— 8 92- DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # 9,,�*,G ( ) 01 YES ( ) 02 NO HSC04-070185• (10/18/85) �' PAGE 2