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STATE ID NUMBER CONTAINER CONSTRUCTION E• 1 1 01 RUBBER LINED ( ) 02 ALKYD LINING 1 ) 03 EPDXY LINING 1 1 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED I)d'08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION Uc1'04 UNKNOWN l 1 05 NONE f ) 06 TAR OR ASPHALT 1 ) 09 OTHER: VI PIPING [A*:A:BOVEGROUND PING ( 1 O1 DOUBLE,WALLEO PIPE ( ) 02 CONCRETE-LINED TRENCH03 GRAVITY CHECK APPRO IATE BOXES) ( 1 04 PRESSURE05 SUCTION t 1 06 UNKNOWN I?7" 07 NONE . UNDERGROUND PI(DING f ) O1 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(E5) ( '1 04 PRESSURE (?6 05 SUCTION (' 1 06 UNKNOWN 1 ) 07 NONE VII LEAK DETECTION l 1 01 VISUAL ( ) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( 1 06 GROUND WATER MONITORING WELLS f 1 07 PRESSURE TEST GCY 09 NONE 1 ) 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 NAVE) , P STORED STORED --.-- ( ] 01 I l 02 f 1 03 l ) 01 ( 1 02 I 1 03 r ( 1 01 ( ] 02 ( 1 03 I I I I I I I I I I I ( ) 01 l 1 02 ( 1 03 I I II III III I ( ) 01 f ) 02 f ) 03 ( ) 01 ( ) 02 l ) 03 ( 1 01 ( ) 02 ( ) 03 ( 1 01 t ) 02 ( ) 03 I I t ) 01 ( ] 02 ( 1 03 l 1 01 f ] 02 ( ) 03 1 1 1 1 1 1 1 ' IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ,( 1 01 YES 102 NO THIS FORM HAS BEEN COMPLETED UNDER THEIR MALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (SIGNATURE)„. PHONE W/AREA CODE FOR LOCAL AGE USE ONLY ADMINISTRATING Art JONCY J CITY CODE COUNTY LODE aG.. r v ` 3 PHONE W/AREA CODE CONTACT PERSON DATE OF LAST INSPCCTION IN COMRLTA NCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 7t ( 1 01 YES f ) 02 NO HSC04-070185 be rary 4vt- / PAGE 2 I— � I