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STATE ID NUMBER 00000036582002 CONTAINER CONSTRUCTION E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP t ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION [ ) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS TORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV -F YOU ARE NOT REQUIRED TO COMP ETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( l 03 ( 101 ( ) 02 ( l 03 ( l 01 ( ) 02 ( 103 ( l 01 ( ) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 ( J 01 ( l 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS [S CONTAINER LOCATED ON AN AGRICULTURAL FARM? (X) 01 YES ( ) 02 NO __ ___.. HAS ..-�., ........�rr� iun THE PENAL TY OF PFR_ URY AND. TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. 11S FORRH nay nrrri wriFL—w v.0 11-.. - -- PERSON FILING (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE PHONE W/AREA CODE CONTACT PERSON DATE OF LAST INSPECTION LIN COMPLIANCE( ) 02 NO I PERMIT APPROVAL DATE I TRANS.ACTION DATE HSC04-070185 (10/18/85) COUNTY CODE LOCAL PEPMIT ID # PAGE 2