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STATE ID NUMBER 00000002420003 CONTAINER CONSTRUCTION E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING f ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. f 1 01 POLYETHLENE WRAP f It 02 VINYL WRAPPING [ ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ] 05 NONE ( 1 06 TAR OR ASPHALT ( 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLEO PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY (CHECK APPROPRIATE BOX(ES) [ 1 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN f 1 07 NONE VII LEAK DETECTION (X) 01 VISUAL (X) 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT ( 1 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE ( 1 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 CUPRENTLY PREVIOUSLY DELETE CASL (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED ( ) 01 ( 1 02 f ) 03 1 ) Ol ( ) 02 1 ) 03 ( ) Ol ( 1 02 ( 1 03 ( l01 ( 102 1 103 ( ] 01 ( ) 02 ( 1 03 ( 1 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( It 02 ( 1 03 ( ) 01 ( ) 02 ( 1 03 • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? l 1 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/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 % ( ) O1 YES ( ) OY NO HSC04-070185 (10/18/85) PAGE 2