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STATE ID NUMBER 00000054576004 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING t 1 03 EPDXY LINING ( } 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) OI POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC -PROTECTION (X) 04 UNKNOWN ( l 05 NONE t ) 06 TAR OR ASPHALT t ) 09 OTHER Vi PIPING A. ABOVEGROUND PIPING- ( ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE'BOX(ES) ( ) 04 PRESSURE .t D 05 SUCTION ( ) 06 UNKNOWN ( D 07 NONE S. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN t ) 07 NONE VII LEAK DETECTION l 01 VISUAL f ) 02 STUCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT 06 GROUND WATER MONITORING WELLS ( 107 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU ARE NOT RE4UIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED t ) 01 ( ) 02 ( ) 03 ( l 01- ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 l 01 ( ) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? E 1 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 FILING (SIGNAT RE) PHONE W/AREA CODE FOR LO- A/ AG6ttY USE ONLY ADMINISTP ING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/ARE.A CODE DATE OF LAST INSPECTIONIN COMPLIANCE PERMIT APPROVAL GAT-E TRANSACTION DATE LOCAL PERMIT ID # ( ) O1 YES ( ) OE NO HSC04-070185 (10/18/85) PAGE 2