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STATE I0 NUMBER CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING l 1 03 EPDXY LINING ( l 04 PHENOLIC LINING l ) 05 GLASS LINING ( l 07 UNLINED (X1'08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING 1 103 CATHODIC PROTECTION (JH-04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROLR40 PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( 1 OS SUCTION ( ) 06 UNKNOWN ()d'07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( 'I 04 PRESSURE ( O5 SUCTION f ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION f 1 01 VISUAL Lktj�02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS 1 ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS Gkr 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 PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAM!) STORED STORED O 01 O 02 O 03 1 1 1 1 1 1 1 1 1 1 1 ( 1 Ol ( ) 02 ( ) 03 1 1 I_llI_I_I I _I I I ( 1 01 ( ) 02 ( ) 03 l 1 Ol ( l 02 ( ) 03 I ( ) 01 ( ) 02 ( ) 03 L I 1 O01 ( 102 ( 1031111111111111 ( 101 1102 11031111 � � � � 11111 _— I 1 01 ( ! 02 ( 1 03 1 1 01 O 02 ( I 03 1 1 01 ( 1 02 ( l 03 IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES 102 NO TrHIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. IPC @SE�FI INIONATURI�f- ----_—_--- PHONC W/AREA COO[ FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE J CO NTA T PEPS ON PHONE W/ARRA CODE rt` DATI OF LAST NSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID S /_-/ ?,� G (M1 Ol VC S (`1 02 NO HSC04-100701857 ' �' �• '" J PAGE 2