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STATE IO NUMBER CONTAINER CONSTRUCTION E. f1'01 RUBBER LINED t 102 ALKYD LINING t ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING. 4 D 07 UNLINED t D 08 UNKNOWN t ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( D 02 VINYL WRAPPING ( ) 03 CATHODIC 'PROTECTION ( D 04 UNKNOWN ( ) 05 NONE ( 1 06 TAR OR ASPHALT t ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: t D 01 DOUBLE-WALLED PIPE ( D 02 CONCRETE-LINED TRENCH ( D 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( D 05 SUCTION ( D 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( 1 DO LE-WALLED PIPE t D 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( D OI VISUAL ( ) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS t D 05 SENSOR INSTRUMENT t ) 06 GP,OUND WATER MONITORING WELLS t D 07 PRESSURE TEST ( D 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 CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STORED ( D 01 ( l 02 ( 1 03 I I I I I I I I I I I I I O 01 t 1 02 O 03 �I ( ) 01 ( ) 02 i 1031 t ) 01 ( l 02 ( ) 03 ( D 01 ( D 02 ( ) 03 �! ( I I I t D01 ( ) 02 ( ) 033 t l 01 ( ) 02 ( 1 03 ( ) 01 _ ( ) 02 ( ) 03 �_ I I III I I t D 01 () 02 11 03J I I I I I I I I I I 1 I ( 101 ( 02 ( 103111111 ( 111 Il IS CO'iTAINER LOCATED ON AN AGRICULTURAL FARM? t ) 01 YES ( D 0 -NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANDS TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. -- PEtSON FI I G (SIGNA- FE ) PHONE W)/AARRE)CODE p q FOR LOCAL AGE Y USE ONLY I111STPATINS AGENCY CITY CODE COUNTY CODE CONTACT O_PcCN PHO E W/ARE CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # ( ( O1 )ES ( ( 02 NO�— ASC04-070185 PAGE 2