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�- STATE ID NUMBER 00000011284002 CONTAINER CONSTRUCTION E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING ( ) 07 UNLINED (X) O8 UNKNOWN ( 1 09 OTHER: F. f ) 01 POLYETHLENE WRAP f l 02 VINYL WRAPPING t ) 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 ( 1 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 ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION WIY O1 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT �1 06 GROUND WATER MONITORING WELLS _�f 07 PRESSlR2E TEST f 1 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) CHEMICAL IDD NOT USE COMMERCIAL NAME ) STORED STORED ( 1 01 ( 7 02 ( ) 03 ( ) 01 f 1 02 ( ) 03 ( ) Ol ( 1 02 ( ) 03 f ) Ol l 1 02 f ) 03 l 1 Ol ( ) 02 ( ) 03 f ) Ol ( 1 02 ( ) 03 ( 1 01 f ) 02 ( 1 03 1 1 Ol ( ) 02 ( ) 03 ( ) Ol ( ) 92 ( ) 03 t 1 Ol ( ) 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. PERS FILING fSIONATU PHONE W/ARF CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AOENCY ( CITY CODE COUNTY CODE CONTAC PERSON PHONE W/AREA CODE --,-o 9-9YY- tea- / DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 0 1 YES ( ) 02 NO HSC04-070185 (_100/18/85) 11"/L 4 ' 2,t--5_ PAGE 2