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\� STATE ID NUMBER 00000064662001 CONTAINER CONSTRUCTION E. l ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING f l 04 PHENOLIC LINING l ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. I ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT l 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING' ( ) 01 DOUBLE-MALLEO PIPE f ) 02 CONCIETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION l ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE l 1 05 SUCTION ( 1 06 UNKNOWN ( i 07 NONE VII LEAK DETECTION l ) 01 VISUAL ( ) 02 STOCK INVENTORY ( 104 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRL11ENT l ) 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 (DO NOT USE COMMERCIAL NAME) STORED STORED (X) O1 ( ) 02 ( ) 03 8 0 0 8 2 0 6 • KEROSENE (PETROLEUM NAPTHA:515 SOLVENT) ( l 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 l 1 O1 ( ) 02 ( ) 03 ( 1 Ol ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 I ) O1 ( ) 02 ( ) 03 f 1 O1 ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 ( ) 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. PERSON FILING (SIGNATURE) PHONE W/APEA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ) 02 NO HSC04-070185 (07/03/87) PAGE 2