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STATE I0 NUMBER 00000034825001 CONTAINER CONSTRUCTION E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( 1 09 OTHER= F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) f ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( 7 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( 7 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION fX) O1 VISUAL f ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( 1 06 GROUND WATER MONITORING WELLS ( l 07 PRESSURE TEST ( 1 09 NONE f l 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-f YOU ARE NOT REGUIREO TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STORED ( ) 01 ( 1 02 ( 1 03 ( 1 O1 f ) 02 ( ) 03 ( ) 01 ( l 02 ( 7 03 ( 1 01 ( ) 02 ( 1 03 ( ) 01 ( 7 02 f ) 03 ( ) 01 ( l 02 ( ) 03 ( 7 Ol ( ) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 4 ) 01 ( ) 02 ( ) 03 ( ) 01 ( 1 02 ( 3 03 ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? (X) 01 YES ( l 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 COV NTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # f 1 01 YES l ) 02 NO HSC04-070185 (10/18/85) PAGE 2