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CONTAINER CONSTRUCTION STATE ID NUMBER 00000063026001 E. ( ) O1 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ] 05 GLASS LINFNG IX) 07 UNLINED ( 1 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETMLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( l 04 UNKNOWN fX) 05 WOKE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVFTY (CHECK APPROPRIATE BOXES) f ) 04 PRESSURE ( 7 05 SUCTION ( 7 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( 101 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXf ES1 ( ) 04 PRESSURE W 05 SUCTION f 1 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( J 06 GROUND WATER MONITORING WELLS Lkf 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL IF YOU CHECKED COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION F) o Y PRj82 ELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) ) 03 1 03 ) 03( 1 03 f 1 03 ( 1 01 f ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( 101 f ) 02 ( 103 f ) 01 ( ) 02 ( ) 03 ( 1 of f ) 02 ( l 03 + CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO THIS FORM HA BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FIL NO (SIGNATURE) PMONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 4 ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2