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STATE ID NUMBER 00000065391004 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( 1 02 ALKYD LINING ( ) 03 EPDXY LINING i ) 04 PHENOLIC LINING ( } 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( 1 09 OTHER: F. ( J 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING t } 03 CATHODIC PROTECTION t 1 04 UNKNOWN (X) OS NONE ( ) 06 TAR OR ASPHALT ( 1 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: t ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) Hft 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION (X) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS (X) 05 SENSOR INSTRUMENT 1 ) 06 GROUND WATER MONITORING WELLS ( } 07 PRESSURE TEST ( ) 09 NONE 1 1 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 CASH (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) STORED STORED (kY Ol 1 ) 02 ( 1 03 (� L ('-J- 01 l 1 02 ( 1 03 J ' ( J 01 f 1 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( ) 01 t ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 i ) 01 i ) 02 ( ) 03 ( J 01 t ) 02 ( l 03 i ) Ol f ) 02 ( 1 03 ( ) Ol ( 3 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 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. PER PHONE W/AR CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PE SON PHO W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ) 02 NO HSC04-070185 (05/05/861 PAGE 2