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v STATE IO NUMBER 00000041808001 CONTAINER CONSTRUCTION E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING f l 03 EPDXY LINING ( ) 04 PHENOLIC LINING l 1 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN f 1 09 OTHER: F_. f ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 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 SOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE S. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH t ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X1 05 SUCTION ( l 06 UNKNOWN ( 7 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ] 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS t 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOV CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STOPED (X) 01 ( ) 02 ( ) 03 ALIPHATIC (225 THINNER) ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 f ) 01 ( ) 02 ( ) 03 ! ) 01 ( ) 02 ( ) 03 f 7 01 ( ) 02 ( ) 03 1 ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( 7 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( 1 03 (t 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 AD NISTP.A NO AGENCY CITY CODE COUNTY CODE �vI/1-rc7G CONT CT PE N PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT ARP ROVAL DATE TRANSACTION DATE LOCAL PCRMIT ID # f 1 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2