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STATE ID NUMBER 00000009658001' ' CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING t l 04 PHENOLIC LINING ( 105 GLASS LINING (X') 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 ,POLYETHLENE WRAP ( J 02 VINYL WRAPPING t } 03 CATHODIC PROTECTION ( l 04 UNKNOWN (X) 05 NONE t ) ,06 TAR OR ASPHALT { J 09 OTHER= VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-"LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE t 105 SUCTION ( D 06 UNKNOWN E l 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXES) (X) 04 PRESSURE: ( ) 05 SUCTION ( J 06 UNKNOWN t l 07 NONE VII LEAK DETECTION D 01 VISUAL (X) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT ) 06 GROUND WATER MONITORING WELLS ( l 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 STOPED t ) 01 ( ) 02 ( ) 03 t 9 01 ( ) 02 ( ) 03 t D 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( 3 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( D 01 ( ) 02 t ) 03 ( l 01 ( ) 02 ( ) 03 f ) 01 ( ) 02 t ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATEDONAN 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 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 TRANSACT%ON DATE LOCAL PERMIT ID # ( ) O1 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2 I