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STATE ID NUMBER 00000054576003 CONTAINER CONSTRUCTION E ( ) Oil RUBBER LINED ( ) 02 ALKYD LINING E J 03 EPDXY LINING f ) 04 PHENOLIC LINING t D 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 'VINYL WRAPPING ( J 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( D 05 NONE ( ) 06 TAR OR ASPHALT f ) 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: E ) 0,1 DOU6LE-WAILED PIPE t } 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION t ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT E ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIPED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STCP.ED 01 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 D 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( 1 0:1 ( ) 02 f ) 03 f ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 t ) 03 ( ) 01 ( ) 02 C ) 03 ( ) 03 ( ) 02 ( ) 03 01 ( ) 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 FILI .3 (SIONATUR PHONE W/AREA CODE x 32d " j/ t FOR L C L A CY 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 D # i ) O1 YES ( ) 02 NO - HSC04-070185 (10/18/85) PAGE 2