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STATE ID NUMBER 00000018096009 CONTAINER CONSTRUCTION ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING i ) 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER. I ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN C l 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: PIPING ABOVEGROUND PIPING: ( l 01 DOUBLE—WALLED PIPE [ ) 02 CONCRETE—LINED TRENCH i ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE UNDERGROUND PIPING! ( ) 01 DOUBLE—WALLED PIPE ( 1 02 CONCRETE—LINED TRENCH (X) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE f ) 05 SUCTION ( l 06 UNKNOWN [ ) 07 NONE FII LEAK DETECTION ( ) 01 VISUAL ( ) 02 STOCK INVENTORY C ) 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 STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CUPP.ENTLY PRE':IOUSLY DELETE CA$# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STOPED STCRBO ( ) 01 ( l 02 ( ) 03 ( 101 ( ) 02 ( } Q31111111111111 ( ) O1 ( ) 02 ( 1 03 o ( ) 01 ( ) 02 ( l 03 ( 1 01 ( ) 02 ( l 03 [ l 01 i ) 02 ( ) 03 ( i 01 ( l 02 ( 1 03 01 ( 1 02 ( ) 03 ( l 01 ( ) 02 f ) 03 E 1 01 ( ) 02 ( l 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 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. PEPSON FILING (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY 'ADMINTSTPAT'NG AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATELOCAL PERMIT 10 # ( ) 01 YES [ 1 02 NO HSC04-070185 (10/18/85) PAGE 2