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STATE ID NUMBER 00000011073004 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED l 1 02 ALKYD LINING t ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING t l 05 GLASS LINING ( 1 07 UNLINED (X) 08 UNKNOWN ( 1 09 OTHER: F. ( ) 01 POLYETHLE14E WRAP t D 02 VINYL WRAPPING t 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( l 05 NONE f ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( D 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING= ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( D 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( l 05 SUCTION t ) 06 UNKNOWN ( l 07 NONE i VII LEAK DETECTION (X) 01 VISUAL (X) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT - - -_ ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS :F YCJ CHECKED YES TO IV-F YOU APE NOT REQU:FED TO COMPLETE THIS SECTION CU=PENTLY FFEV:OUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) ST„=E0 S7„, EO ( ) 01 ( ) 02 ( ) 03 t ) 01 f ) 02 O 03 ( ) 01 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( 1 03 t ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( 1 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 l 1 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03� 1 * 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. PEFSCN F-4LiNG (S:GNATUFE ) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADM:NIST04TIN3 AGENCY CITY CODE COUNTY" CODE CCN74CT PEPSCN PHONE W/AREA CODE P �GA.T= OF LAST :NSFECT:ON IN COMPLIANCE ERMIT APPPOVAL DATE TPANSACTION DATE LCCAL PEFMIT ID 4 01 IE S 1 ) 02 NO � -- �- _- HSC04-070185 (10/18/85) PAGE 2