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FM STATE ID NUMBER 00000003324001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( l 04 PHENOLIC LINING ( l 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( l 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: ( VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( l 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ---= ( ) O1 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 105 SENSOR INSTRUMENT ( l 06 GROUND WATER MONITORING WELLS t l 07 PRESSURE TEST ( ) 09 NONE ( l 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 STOPED — (X) 01 ( ) 02 ( ) 03 16141714121-14171_-181 NOT ON LIST ( 1 01 ( ) 02 ( ) 03 — ( ) 01 ( ) 02 ( ) 03 ( 1 O1 ( 1 02 ( ) 03 ( l 01 f l 02 ( ) 03 — ( 1 01 ( l 02 ( ) 03 ------ ( l 01 t ) 02 ( ) 03 ( ) 01 ( 102 ( ) 03 t l 01 ( ) 02 ( ) 03 ( 1 01 O 02 O 03 I I I I I I I * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IIS 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 Ec CITY CODE COUNTY ODE ADMINISTRty=.IN^v AGENCY U . G PHONE W/AREA CODE CONTACT PERSON OATS OF LAST INSPECT20N IN�COMPLIANCE �02 PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # 2_ ( ES ( PAGE 2 HSC04-070185 (10/18/85)