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STATE ID NUMBER 00000000726004 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING l ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 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: f ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( l 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 CURRENTLY STORED PREVIOUSLY STORED DELETE C.AS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) ( l 01 ( ) 02 ( l 03 ( ) 01 ( ) 02 ( ) 03 I I I ( l 01 ( ) 02 ( ) 03 ( ) O1 ( ) 02 ( l 03 I I I ( ) 01 ( ) 02 ( ) 03 01 ( ) 02 ( l 03 l ( ) 01 ( l 02 ( l 03 ( l 01 ( ) 02 ( 1 03 ( ) 01 ( ) 02 ( ) 03 01 ( l 02 ( ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS 1S CONTAINER L TED ON AN GRICULTURAL FARM? ( ) 01 YES (X) 02 NO ';HI'.i FORM HAS BE t 'CO LET UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. fP'eF"">ON FILINGV13.U P. PHOtjE W/.ARE.A CODE FOR LOgAk AGENCY USE ONLY IADMINYSTPAT NG AGENCY p� CITY CODE COUNTY CODE JG. t GL � �t e�( L� CONTACT PERSON PHONE W/ARE CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT .APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( 1 02 NO HSC04-070165 (10/18/85) PAGE 2