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STATE ID NUMBER 00000048924002 CONTAINER CONSTRUCTION E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING f ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. [ ) '01 POLYETHLENE WRAP [ l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION {X) 04 UNKNOWN I ) 05 NONE ( ) 06 TAR OR ASPHALT ( 1 09 OTHER= VI PIPING A. A.BOVEGROUNO PIPING. ( ) 01 DOUBLE-WALLED PIPE ( ) 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 t 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( l 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN t l 07 NONE VII LEAK DETECTION {X) 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( 1 06 GROUND WATER MONITORING WELLS ( ] 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 RE.UIREO TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CASU SIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) STORED STORED ( ) 01 ( ) 02 ( ) 03 f l 01 O 02 O 03 I I I I I I I l l l l f ) 01 t ) 02 ( 1 03 f 7 01 f 1 02 ( ) 03 [ ) 01 ( l 02 ( 1 03 ( 1 01 { 1 02 ( 1 03 ( ) 01 ( 1 02 ( 1 03 ( ) 01 ( 1 02 ( 1 03 ( ) 01 ( J 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGEr IS TRUE AND CORRECT. PERSON FILING (SIGNATURE) - PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY A0MiNiS7RA7IN3 AGENCY CITY CODE COUNTY CODE CCNTACT ;EPSON PHONE W/AREA CODE DATE OF LEST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID tt ( Y 01 YES ( ) 02 NO HSC04-070x85 (10/]8/85) PAGE 2