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STATE ID NUMBER 00000028920003 `CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( 1 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( 1 09 OTHER VI PIPING A. ABOVEGROUND 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 ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION [ l 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ds I OI VISUAL ( ) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS f ) 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 RECUIPED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( 1 02 ( ) 03 ( ) 01 ( 1 02 ( ) 03 ( ) 01 ( l 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 f ) 01 ( ) 02 ( 1 03 ( 1 01 ( 1 02 ( 1 03 ( ) OI ( ) 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 HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PHONE W/AREA CODE PERSON FILING (SIGNATUPE) FOR LOCAL AGENCY USE ONLY CITY CODE COUNTY CODE ADMINISTRATING AGENCY PHONEW/AREAA CONTACT PERSONDATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TE LOCAL PERMIT ID R ( ) 01 YES ( 1 02 NO PAGE 2 HSC04-070185 (10/18/85)