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140. STATE ID NUMBER 00000019658001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) ALK YO 02 YD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) OS GLASS LINING 1X) 07 UNLINED ( ) 00 2 LKWN ( ) 09 OTHER: F. t ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE (X) 06 TAR OR ASPHALT ( ] 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 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 ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (XI 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) STORED STOPED ( ) 01 ( 7 02 ( ) 03 ( 1 01 ( l 02 ( 1 03 f ] 01 ( 1 02 ( ) 03 ( ) 01 f ) 02 f ) 03 ( l 01 ( ) 02 ( ) 03 ( ) 01 f ) 02 ( ) 03 ( 1 91 ( l 02 ( ) 03 ( ) O1 ( ) 02 ( l 03 f 7 O1 l 7 02 ( ) 03 ( 1 01 ( ) 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 n BEEN COMPLETED xD-ElAnPENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. ERSO F' (SIGNATURE) PHO /AR COOS FOR LOCAL AGENCY USE ONLY ADMIN STRATZ AGENCYCITY CODE .COUNTY CODE CONTACT P SON PH HE W/AREEAA CODE Z DATE' OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( I 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2