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STATE ID NUMBER 00000013908004 CONTAINER CONSTRUCTION E. ( l 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( l 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( 1 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION ( l 04 UNKNOWN (X) 05 NONE ( ) 06 TAP, OR ASPHALT ( l 09 OTHER. VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( l 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) (X) 04 PRESSURE f 1 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION (X) 01 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YCJ CHECFED YES TO !V-F YOU APE NOT PECUIPED TO COMPLETE THIS SECTION CUPPENTLY FF E'VICUSLY DELETE C.AS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) STORED STOPED ( 1 01 ( l 02 ( ) 03 ( 1 01 ( 1 02 ( l 03 ( l 01 ( l 02 ( l 03 ( 1 01 ( l 02 ( ) 03 ( ) 01 ( l 02 ( ) 03 ( 1 01 ( ) 02 ( 1 03 f ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( l 03 ( ) 01 ( ) 02 ( l 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. ?EPSON FILING (SIGN.ATUPE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSCN PHONE W/.AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2