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STATE ID NUMBER 00000062887004 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN f ] 09 OTHER: F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN (L 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION f ) 06 UNKNOWN W 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( 1 06 GROUND WATER MONITORING WELLS jj�L07 PRESSURE TEST f 1 09 NONE ( 1 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 CUPPENTLY PPE'.'ICJSLY DELETE CAS# (IP KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STOPED ( ) 01 [ ] 02 ( ) 03 ( ) 01 ( ) 02 f ) 03 I I I ( ) 01 ( 1 02 ( ) 03 f ) 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( ) Ol ( 7 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS 'S CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO IS FORM AS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. EPSON IL NG (SIGNATUR• PHONE W/AREA OODE a � 3 _ A OR LOCAL AGENCY USE ONLY iMINISTRASING AGENCY CITY CODE COUNTY CODE NTACI, PERSON 0 PHONE W/AREA CODE h C �S� TE OF LAST INSPECTION'/ IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 Y,7E�YSp� ( ) 02 NO )4-070185 (10/18/85) /( A) PAGE 2 i r