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STATE ID NUMBER 00000062513002 CONTAINER CONSTRUCTION E. f 7 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( 1 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN f ] 05 NONE ( ) 06 TAR OR ASPHALT ( 109 OTHER: VI PIPING A. ABOVEGROUND PIPING ( ) 001 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 ( ) 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION f l 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS [ ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS f l 07 PRESSURE TEST ( ) 09 NONE f 1 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 CURRENTLY PREVICUSLY DELETE CAER (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STOP=D ( 1 01. ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 f 1 Ol ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( .1 01 f ) 02 ( ) 03 f ] Ol ( 1. 02 ( 1 03 ( 1 01 ( 7 02 ( ) 03 ( ) 01 f ) 02 ( ) 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 (SIGNA RE ) PHONE W/A REQA ODE l � FOR LOCAL AGENCY USE ONLY ADM NISTRAT'NG AGENCY CIT'G{O COUNTY CODE CONT CT PERSO PV6NE W/A A CO 17 DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID it ( ) 01 YES f ) 02 NO HSC04-070185 (10/18/85) PAGE 2