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STATE ID NUMBER 00000006731001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER. F. C ) 01 POLYETHLENE WRAP € ) 02 VINYL WRAPPING ( 3 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ] 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY (CHECK APPROPRIATE BOX(ES) C ) 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) ( ) 04 PRESSURE CX) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION C ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST C ) 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 CUPRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) STOPED STCPED __ 1 ( ) 01 [ ) 02 ( ) 03 ( ) 01 ( 1 02 C 1 03 - --- C 1 01 ( ) 02 f 3 03 ( 1 01 ( ) 02 ( 1 03 ( ) 01 ( ) 02 ( ) 03 i ) 01 f 1 02 ( ) 03 ( ) 01 ( ) 02 C ) 03 E ) 01 ( ) 02 ( 1 03 ( ) 01 ( ) 02 ( l 03 C ) 01 ( ) 02 ( ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? E 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 FIG ) PHONE W/AREA CODE 7' d FOR LOCAL AGENCY USE ONLY ADMINISTRATIN3 AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE COD ��^ / � AP _ ct DA'rE CF LAST NSP'eCTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID f 7 ( ) 01 YES t ) 02 N0 PAGE 2 HSC04-070185 UUU(10/18/85)