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STATE ID NUMBER 00000053281001 CONTAINER CONSTRUCTION E. ( 7 01 RUBBER LINED ( 1 02 ALKYD LINING ( ) 03 EPDXY LINING f ) 04 PHENOLIC LINING f l 05 GLASS LINING f 1 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE f ) 06 TAR OR ASPHALT f ] 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE CA) 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 V 05 SUCTION (t) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION f ) 01 VISUAL (X) 02 STOCK INVENTORY ( ). 04 VAPOR SNIFF. WELLS ( 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 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 CUFFENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STOPED STORED ( l O1 ( ) 02 ( 1 03 ( ) 01 f ) 02 ( 1 03 ( 1 O1 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 f ) 03 f ) 01 ( 1 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( 1 03 ( l 01 f ) 02 ( 1 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/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 # ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2