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STATE ID NUMBER 00000027085005 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. ( l 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION f l 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: ( ) 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 ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPCR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE (X) 10 OTHER: LINE LEAK DETECTORS VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF 1CU CHECKED YES TO IV-F YOU ARE NOT RE9UIRED TO COMPLETE THIS SECTION CURRENTLY PPEVIO'USLY DELETE GASSY (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STCMED ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( l 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( l 03 I 1 ( ) 01 ( 1 02 ( l 03 f ) 01 ( ) 02 ( 1 03 ( ) 01 ( l 02 ( l 03 ( l 01 t ) 02 t ) 03 ( ) 01 ( 1 02 ( ) 03 ( l O1 ( l 02 ( ) 03 ' * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO HIS 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 ADMINISTRATING AGENCYLo /� � CITY�DE COUNTY CODE CONTACT F° 0� 0 PHONE W/ARE.A COD DATE OF LAST INSPECTION JIN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( 1 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2