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CONTAINER CONSTRUCTION STATE ID NUMBER 00000008304001 E) Ol R LINED ( ] 02 ALKYD LINING ( ] 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING LINED (X) 08 UNKNOWN ( ) 09 OTHER: THLENE WRAP ( 1 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X] 04 UNKNOWN ( ) OS NONE R OR ASPHALT ( ) 09 OTHER: VI PIPING EABOVEGROUNDPIPING• ( ) 01 DOUBLE-WALLED P PE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY PRIATE BOXfES) ( 1 04 PRESSURE OS SUCTION f 1 06 UNKNOWN ( ] 07 NONE PIPING: ( ) O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY PRIATE BOX(ES1 ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION f l 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT f ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( 1 30 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS :F YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CUPPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) STORED STORED CHEMICAL (DO NOT USE COMMERCIAL NAME) ( 1 01 ( ) 02 ( ) 03 c l01 ( ) oz f 1031 I ( ) Ol ( 102 ( 7 03 ( l 01 ( l 02 ( ) 03 ( ) 01 f ) 02 ( 1 03 f ) 01 ( 1 02 ( ) 03 ! 7 01 ( 1 02 ( 1 03 L::,:al ( ) '02 ( ) 03 :: 01 f l 02 ( ) 03 ( ) 02 ( 1 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO THIS FORM H BEEN COMPLET N TH PENAL OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FIL SI NAT RE) PHONE W/AREA CODE D FOR L C L AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE ' DA`TE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE ( ) 01 YES ( 1 02 NO LOCAL PERMIT TO # HSC04-070185 (10/18/85) PAGE 2