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STATE IO NUMBER 00000052462001 CONTAINER CONSTRUCTION E. [ 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( 1 09 OTHER: F. ( 1 01 POLYETHLENE WRAP ( 7 02 VINYL WRAPPING ( ] 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE ( ) 06 TAR OR ASPHALT ( 7 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 ( 1 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION ( l 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROU TER MONITORING WELLS ( 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 (DO NOT USE COMMERCIAL NAME) STORED STORED ( ) 01 ( ) 02 ( 1 03 ( ) 01 ( 1 02 ' ( ) 03 ( ) 01 ( ) 02 ( )' 03 ( ) 01 ( ) 02 ( 7 03 (. ) 01 ( ) 02 ( 1 03 ( ) 01 ( ) 02 ( ) 03 f 7 01 ( ) 02 ( ) 03 (. ) 01 ( ) 02 ( ) 03 f ) 01 ( ) 02 ( 1 03 ( l 01 ( ) 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 TH5 PE14ALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (SIGNATURE) PNO NE W/AREA CODE to - 9�ff FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODECOUNTY CODE Qu [4 C, +r-_AL. 1 CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # z� 5"�_�G ( ) O1 YES ( 7 02 NO HSC04-070185 (10/18/851 PAGE 2