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STATE I0 NUMBER 00000023912001 CONTAINER CONSTRUCTION E. 1 ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING f 1 04 PHENOLIC LINING ( 1 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN t ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE ( ) 06 TAR OR ASPHALT f ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING' ( 1 01 DOUBLE-WALLED PIPE ( ] 02 CONCRETE-LINED TRENCH t ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES1 ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE f 1 05 SUCTION ( ) 06 UNKNOWN f ) 07 NONE VII LEAK DETECTION ( 1 O1 VISUAL ( ) 02 STOCK INVENTORY f l 04 VAPOR SNIFF WELLS f ) 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 ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STORED t 1 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( 1 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( 1 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 t 101 ( ) 02 ( ) 03 ( 1 al ( ) 02 ( 1 03 ( ) 01 ( ) 02 ( 1 03 • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? (X) 01 YES ( ) 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 ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION INCOMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) O1 YES ( l 02 NO HSC04-070165 (10/18/85) PAGE 2