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0 STATE ID NUMBER 00000010781006 CONTAINER CONSTRUCTION _ C l 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING E. 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. i 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (Xl 05 NONE ( ) 06 TAR OR ASPHALT ( l 09 OTHER: VI PIPING A. ABOVEGROUND PIPING- E ) 01 DOUBLE-WALLED PIPE C ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( f 01 VISUAL (X) 02 STOCK INVENTORY [ D 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( ) Ob GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST f ) 49 NONE iX] IO OTHER LINE LEAK DETECTORS VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU APE NOT REgUIP.ED TO COMPLETE THIS SECTION CURRENTLY PPEVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORE" STOPED ( l 41 ( ) 02 ( ) 03 l 01 [ l 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 f ) 01 ( 1 02 ( 1 03 01 ( ) 02 ( 1 03 i ) 01 ( ) 02 ( 1 03 ( ) 01 ( 1 02 ( ) 03 t ) 01 ( 1 02 ( 1 03 ( ) 01 ( 3 02 ( 1 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 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/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE WlAREA CODE DATE OF LAST INSPECTION IN COMPLIANCE �Z_ N PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # ( ) 01 'YES ( ) PAGE 2 HSC04-070185 (10/18/85)