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STATE ID NUMBER 00000017975001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( J 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( 102 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUN4 PIPING: ( ) 01 DOUBLE-WALLEjJ .PIPE t l 02 CONCRETE-LINED TRENCH ( l 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 (X) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (>O 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION (X) 01 VISUAL (X) 02 STOCK INVENTORY t l 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 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 PREVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STOPED ( ) 01 ( 1 02 ( ) 03 ( ) 01 ( 3 02 ( ) 03 01 ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 ( ) 01 ( l 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 { ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 ( ) 01 C ) 02 ( ) 03 t ) 01 ( l 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE ffNALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (SIGNATUR PHONE W/AREA CODE j FOR LOCAL AGENCY USE ONLY ADMINISTRATIN3 AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/.AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2