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is • "E ID NUMBER 00000032726001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 7 03 EPDXY LINING f ) 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 7 03 CATHODIC PROTECTION (X) 04 UNKNOWN f ] 05 NONE ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ] 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION f ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION (X) 01 VISUAL ( ) 02 STOCK INVENTORY I 1 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT I ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE ( ) 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 CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STOPED STORED ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 l ) 01 4 ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 f ) 01 ( ) 02 ( ) 03 f ] 01 f ) 02 ( ) 03 f 1 01 ( ) 02 f ) 03 ( 7 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 f 1 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES ( ) 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 ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2