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• • STATE ID NUMBER 00000038814001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING f ) 04 PHENOLIC LINING ( 7 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ! ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE ( 1 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE f l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ) 04 PRESSURE ( 1 05 SUCTION jjftj6 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) WS 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN 00 07 NONE VII LEAK DETECTION (X) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 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 PEPUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED l 1 01 ( ) 02 ( ) 03 ( 1 01 ( 1 02 f ) 03 ( 7 01 ( ) 02 f 1 03 ( 7 01 ( 102 ( ) 03 ( 7 01 ( 7 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( 1 03 ( 1 01 ( ) 02 ( ) 03 ( 7 01 ( ) 02 ( ) 03 ( 1 01 ( 7 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 FiLZNG (SIGNATURV) PHONE W/AREA CODE $,�Q 7 9- //6 2 -4 FOR LOCAL AGENeY� USE ONLY ADMINISTRATING AGENCY ��. CITY CODE COUNTY CODE . Jf /J/ ✓ /*jy//✓ L-d 0137, CONTACT PERSOJ ��..L PHONE W/AREA CODE ( _A?7 d DATE OF LAST INSPE TION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTIO/NN DATE aLOCAL PERMIT ID # /I Sj ( ) 01 YES ( ) 02 NO HSC04-070/185 (10/18/85) PAGE 2