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STATE ID NUMBER 00000032875004 CONTAINER CONSTRUCTION E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING l 1 05 GLASS LINING ( ) 07 UNLINED (X) OB UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING [ 7 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( l 05 NONE ( ) 06 TAR OR ASPHALT t 7 09 OTHER: VI PIPING A. ABOVEGROUND PIPING( ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TR NCH ( 1 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( 7 04 PRESSURE ( 1 OS SUCTION ( ) 06 UNKNOWN. ( 7 07 No B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TR NCH (X) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN [ ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS f 1 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 (00NOTUSE COMMERCIAL NAME) STORED STORED ( ) 01 ( 1 02 ( ) 03 ( 1 01 [ 1 02 ( ) 03 ( ) 01 . l ) 02 ( ) 03 ( 7 01 ( 7 02 ( 1 03 ( 1 01 ( 1 02 ( ) 03 ( l 01 t ) 02 ( ) 03 ( ) 01 [ l 02 [ 1 03 ( 1 01 f ) 02 ( ) 03 ( 1 O1 ( 1 02 [ ) 03 ( 1 01 f ) 02 t 1 03 • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINERLOCATED ON AN AGRICULTURAL FARM? ( ) O1 YES (X) 02 NO THIS ORM AS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PE SON (SI NATURE) 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 # f ) 01 YES ( 1 02 NO PAGE 2 HSC04-070185 (10/18/85)