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' STATE ID NUMBER 00000047797006 CONTAINER CONSTRUCTION F. ( ) 01 P.UBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( l 04 PHENOLIC LINING ( l 05 GLASS LINING (X), 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( l 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( l 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( l 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 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 .APE NOT REQUIP.ED TO COMPLETE THIS SECTION CUPPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STOPED STOPED ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( l 02 t l 03 ( l 01 ( l 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( l 01 f ) 02 ( ) 03 f l 01 ( l 02 t l 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( l 03 ( ) 01 ( ) 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. PERSON FILING (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTPATING .AGENCY CITY CODE COUNTY CODE CONTACT PEPSCN PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE JPEPMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2