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STATE ID NUMBER 004,00001276010 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYO LINING ( 1 03 EPDXY LINING t ) 04 PHENOLIC LINING E 3 05 GLASS LINING (X)'07 UNLINED ( ) 08_UNKNOWN ( J 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( ) -03 CATHODIC PROTECTION ( ) 04 UNKNOWN { ) 05 NONE (X) 06 TAR OR ASPHALT E ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( )' 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: E ) 01 DOU8LE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X1 04 PRESSURE I ) 05 SUCTION t l 06 UNKNOWN f D 07 NONE VII LEAK DETECTION =( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( D 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( ) 09 NONE ( ) 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 PPEVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED (X) 01 ( ) 0.2 ( ) 03 B 0 0 8 2 06 1 1 1 1 * KEROSENE (PETROLEUM NAPTHA:515 SOLVENT) ( ) 01 ( ) 02 ::, ( I03 O01 ) 02 ( 10 E l 01 4 ) 02 ( D 03 f D 01 ( ) 02 ( D 03 ( ) 01 t ) 02 (- ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 [ ) 02 ( ) 03 { ) 01 ( ) 02 ( ) 03 ( ) 01 { l 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 FIGI G P.E) RHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PH NE W/AREA CODE DATE OF LAST INSPECTIONIN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE -LOCAL PERMIT ID # ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2 1.