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STATE ID NUMBER 00000056569002 CONTAINER CONSTRUCTION E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING f 1 03 EPDXY LINING f 1 04 PHENOLIC LINING f 7 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f 7 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE ( ) 06 TAR OR ASPHALT l ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 105 SUCTION ( 1 06 UNKNOWN 1 1 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN f 1 07 NONE VII LEAK DETECTION ( ) 01 VISUAL C ) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS (X) 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 OAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED ( ) O1 ( ) 02 f ) 03 ( 1 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 f ) 03 ( ). O1 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 l ) 02 ( ) 03 ( ) O1 ( ) 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) PH rnN9E W/AR CODE FOR LOCAL AGENCY USE ONLY ADMIN TRATIN AGENCY C13Y DE COUNTY CODE LJG CONTAC PE SON t PHOIE W/ARE CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSSAAICTION DATE S LOCAL PERMIT ID # f ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2