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STATE ID NUMBER 00000018681001 CONTAINER CONSTRUCTION E. i 101 RUBBER LINED ( ) 02 ALKYD LINING f 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING ( ) 07 UNLINED (X) OB UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES1 ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY {CHECK APPROPRIATE BOX(ES) f ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( l 07 NONE VII LEAK DETECTION (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( 7 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 (00 NOT USE COMMERCIAL NAME) STORED STORED ( 1 01 f ) 02 f ) 03 ( 1 01 ( 1 02 ( 1 03 ( l 01 f ) 02 ( 1 03 ( ) 01 ( ) 02 ( ) 03 ( l 01 i ) 02 ( ) 03 ( 1 01 ( l 02 f ) 03 ( l 01 ( ) 02 ( 1 03 f l 01 ( 1 02 ( 1 03 ( ) 01 ( 1 02 ( 1 03 ( 1 01 ( 1 02 f ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAIN€R LOCATED ON AN AGRICULTURALFARM? ) YES (X) 02 NO THIS FORM HAS BEEN COMPLETED UNDERY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. PERSON FILING (SIGNATURE) PHONE W/APE4 CODE 2- q q 6 to - o c)a FOR LOCAL AGY E ONLY ADMINISTRATIN AGENCYi� FSAE TO UNTY CODE CONT. T PERSON PHONE W/AREA CODE i - L 4 4O DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( 1 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2 0