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STATE ID NUMBER 00,000063247004 CONTAINER CONSTRV-CTION E. ( ) 01 RUBBER LINED ( T 02 ALKYD- LINING t 1 03 EPDXY LMING 04 PHENOLIC LINING 05 GLASS LINING (X) 01 UNLINED t ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP 02 VINYL WRAPPING 0,3 CATHODIC PROTECTION 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT 09 OTHER: VI PIPIN-G 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 UOUBLE-WALLED PIPE ( ) 02,C0NCPETE-LlNg9 TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOM ES) 1 04 PRESSURE 05 SUCTION C 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION 01 VISUAL (X) 02 STOCK INVENTORY 04 VAPOR SNIFF WELLS t l 05 SENSOR INSTRUMENT 06 GROUND WATER MONITORING WELLS C 07 PRESSURE TEST 09 NONE J ) 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 PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED 01 ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 ol o? 01 t, l 02 _012 t 02 1 1 13 t a 01 1 .02 ( ) QL[ 01 ( J 02 ( ) 03 01 ( l op ( ) 03 01 ( 02 ) 03 01 t ) :02 t ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? 01 YES (X,) 02 NO HIS FOR HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANDA TO THE BEST OF 14Y KNOWLEOGEt IS TRUE AND CORRECT. I- PERSO NO CSZGN NE W/AREA CQ E ILI(t 0 FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE !DATE E OF LAST INSPECTION IN COMPLIANCE IPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 Et 01 YES 02 NO HSC44-070185 (10/18/85) PAGE 2 ----------