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STATE ID NUMBER 00000012631004 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( l 04 PHENOLIC -LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT `t ) 09 OTHER ' VI PIPING 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 DOUBLE-WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( D 05 SENSOR INSTRUMENT ) 06 GROUND WATER MONITORING WELLS t ) 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 XV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CASH (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STOPED ( 3 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 91 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) O1 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 01 ( ) 02 ( ) 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 ANDa TO THE BEST Of MY KNOWLEDGEa IS TRUE AND CORRECT. PERSON FILING (SIGNATURE)( a % PHONE WOAREA CODE FOR LOCAL ,AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE" . CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLZ:4NCE PERMIT' APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # 02 NO HSC04-070185 (10/18/85) PAGE 2