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• •NTAINER CONSTRUCTION STATE ID NUMBER 00000014048001 E. f ) Ol RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f 1 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. f ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE ( ) 06 TAR OR ASPHALT f 1 09 OTHER: - VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN f ) 07 NONE B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN 1 1 07 NONE VII LEAK DETECTION ( 1 01 VISUAL (X) 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( 1 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 CAS# IIF KNOWN) STORED STCPED CHEMICAL f00 NOT USE COMMlPCIAL NAME) ( ) 01 ( l 02 f 1 03 ( ) 01 ( ) 02 f l 03 f 1 01 ( ) 02 f 1 03 ( ) O1 ( ) 02 ( I 03 ( ) 01 ( ) 02 ( ) 03 ( l Ol ( 1 02 ( 1 03 ( 1 01 f ) 02 ( 1 03 1 I Ol f 1 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( 101 ( ) 02 1 1 03 • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO HIS 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 OR LOCAL AGENCY USE ONLY \DMINISTRATING AOENCY CITY CODE COUNTY CODE )CNTACT PERSON PHONE W/AREA CODE :ATE OF LAST :NSP!CTION IN COMPLIANCE PERMIT APPROVAL 047E TRANSACTION DATE LOCAL PERMIT ID # ( l O1 YES 1 1 02 NO IC04-070185 (10/18/85) PAGE 2