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STATE ID NUMBER 00000012631001 CONTAINER CONSTRUCTION E. ( J 01 RUBBER LINED ( ) 02 ALKYD LINING f )'03 EPDXY LINING f ) 0.4 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( l 09 OTHER: F. ( l 01 POLYETHLENE .WRAP t ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION t ) 04 UNKNOWN (X) 05 NONE ( l 06 TAR OR ASPHALT t } 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: t ) 01 DOUBLE—WALLED PIPE ( D 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 t 1 05 SUCTION ( } 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION t ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS { ) 07 PRESSURE TEST ( ) 09 NONE (X) 10 OTHER: LINE LEAK DETECTOR 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 (00 NOT USE COMMERCIAL NAME) STORED STORED ( ) 01 ( J 02 f ) 03 E 101 ( ) 02 ( l 03 ( ) 01 t } 02 ( 'J 03 f l 01 E ) 02 t ) 03 ( l 01 f } 02 f l 03 t l 01 ( ) 02 ( l 03 E ) 01 ( ) 02 ( ) 03 t l Ol ( -) 02 ( ) 03 €. ) 01 E ) 02 ( ) 03 f l 01 t J 02 ( ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? { ) 01 YES (X) 02 N0 THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGEa IS TRUE AND CORRECT. PERSON FILING (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID ( ) 01 YES ( ) 02 N0 HSC04-070185 (10!18/85) PAGE 2