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• STATE ID NUMBER 00000003452002 CONTAINER CONSTRUCTION E. t 1 O1 RUBBER LINED ( ) 02 ALKYD LINING C ] 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( } 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER' F. C ) 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ) 06 TAR OR ASPHALT [ ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( 1 01 DCUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH C ) 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 ( ) 03 GRAVITY (CHECK APPROPRIATE BOXCES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION FO1 VISUAL (X1 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ) 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( ) 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 �- CURRENTLY PREVIOUSLY DELETE GAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAMe- 1 STOPED STORED ( 1 01 ( ) 02 ( 1 03 -- - ( ) 01 f 1 02 ( ) 03 - - ( 1 01 ( D 02 ( 1 03 ( ) 01 C ) 02 ( 1 03 ( 1 01 ( 1 02 ( 1 03 - ( ) 01 ( 1 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 C ] 01 t ) 02 i ) 03 t 1 01 C 1 02 C 1 03 ( 1 01 ( 1 02 I ) 03 1 Lt I I I * 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 4 SIGNATURE) PHONE FW tl r FOR LOCAL AGENCY USE ONLY ACMINISTRATING AGENCY CITY CODE COUNTY- CODE � I 4vf_C-f CONTACT PERSON PHONE W/AREA CODE L( des 1 `o . DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT .D ( ) 01 YES S ) 02 NO PAGE 2 HSC04-070185 (10/18/85)