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STATE ID NUMBER 00000018304006 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( 1 02 ALKYD LINING ( ) 03 EPDXY LINING [ ) 04 PHENOLIC LINING ( J C5 GLASS LINING (X) 07 UNLINED f ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING [ 1 03 CATHODIC PROTECTION i ) 04 UNKNOWN i 1 05 NONE (X) 06 TAR OR ASPHALT [ ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: t 1 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( J 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( J 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 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 REwUIRED TO COMPLETE THIS SECTION CURRENTLY PREVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STOPED STDR__O ( ) 01 ( ) 02 ( 1 03 ( 1 01 ( J 02 ( 1 03 I 1 01 ( 1 02 ( ) 03 ( ) 01 f 1 02 ( 1 03 ( 1 01 ( ) 02 ( 1 03 ( ) 01 ( J 02 ( l 03 ( ) 01 ( 1 02 ( 1 03 ( ) 01 ( 1 02 ( J 03 ( ) 01 f 1 02 ( 1 03 ( 1 01 ( ) 02 ( 1 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/APEA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/..ARFA CODE OAT! OF LAST INSPECTION IN COMPLIANCE pEPMIT .APpROV.AL DATE TRANSACTION DATE LOCAL PERMIT IO 4 ( ) 01 YES ( 1 0$ NO HSC04-070185 (10/18/85) PAGE 2