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CONTAINER CONSTRUCTION STATE ID NUMBER 00000019742001 E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING FA. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH [ ) 03 GRAVITY CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 7 06 UNKNOWN ( 1 07 NONE NDERGROUND PIPING: ( ) O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 103 GRAVITY CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (X1 05 SUCTION ( 7 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION p,(X) 01 VISUAL ( 7 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 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) STORED STORED CHEMICAL (00 NOT USE COMMERCIAL NAME) ( 1 01 ( ) 02 ( 7 03 ( ) 01 ( ) 02 _ ( ) 03 ( ) 01 f ) 02 ( 7 03 ( 1 Ol ( ) 02 ( ) 03 ( ) O1 ( Y 02 C ) 03 f l 01 ( 7 02 f 1 03 ( ) al ( ) 02 ( 1 03 ( '1 01 f 1 02 [ 7 03 ( ) 01 f ) 02 ( ) 03 ( ) Ol ( 1 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATC TRANSACTION DATE ( ) O1 YES ( ) 02 NO LOCAL PERMIT ID # HSC04-070185 (10/18/85) PAGE 2