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CONTAINER CONSTRUCTION STATE IO NUMBER 00000007433001 t ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING f 1 04 PHENOLIC LINING ( 1 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER. f ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 HONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: I PIPING fL- ABOVEGROUND PIPING- f ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE iEi. UNDERGROUND PIPING) f ) Ol DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE AMI LEAK DETECTION 10() 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS l ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: 4111 CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS .F YOU CHECKED YES TO IV•F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION ,.QPFENTLY PPEVICUSLY DELETE CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STOPED STORED (` l 01 ( ) 02 ( ) 03 (( I Ol ( ) 02 ( ) 03 I I I (11 Ol ( ) 02 ( ) 03 If( 01 ( ) 02 ( ) 03 ff ) 01 ( ) 02 ( ) 03 (! ) 01 ( ) 02 f ) 03 (f ) 01 ( ) 02 ( ) 03 (f ) 01 ( ) 02 ( ) 03 1' ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IB CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. 'FtT SON FILZNG (SIGNATURE) PHONE W/AREA CODE i R LOCAL AGENCY USE ONLY '?ISNISTRATING AGENCY CITY CODE COUNTY CODE SbNTACT PERSON PHONE W/AREA CODE SATE OF LAST INSPECTION IN COMPLIANC[ PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO ! ( ) 01 YES ( ) 02 NO SC04-070185 (10/18/85) PAGE 2 y