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STATE ID NUMBER 00000008404001 CONTAINER CONSTRUCTION E. ( l 01 RUBBER LINED C ) 02 ALKYD LINING f 3 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING (Xl 07 UNLINED C ) 08 UNKNOWN ( ) 09 OTHER= F. C ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION C ) 04 UNKNOWN (XI 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 ROUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING' [ 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ] 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( l 07 NONE VII LEAK DETECTION f l 01 VISUAL ( ) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST (X) 09 NONE ( ] 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YCU 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 ( 1 01 f ) 02 ( 1 03 ( ) 01 ( ) 02 ( 1 03 ( ) 01 ( ) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 ( ) 01 f ) 02 [ 1 03 f ) 01 1 ) 02 ( 1 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 { ) 01 C l 02 C ) 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 FILING (SIGNATURE ) 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 ## ( ) 01 YES ( 1 02 NO HSC04-070165 (10/18/85) PAGE 2