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' STATE ID NUMBER CONTAINER CONSTRUCTfoN . 1 ) 01 RUBBER LINED '( ) 02 ALKYD LINING. 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ls3 05 GLASS LINING , 1 1 07 UHLIt�ED ( 1 08 UNKNOWN ( 1 09 OTHER: . E 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( , 03 CATHODIC PROTECTION 1 1 04 UNKNOWN (.-;) 05 NONE 1 1 06 TAR OR ASPHALT 1 1 09 OTHER: J -- I PIPING ABOVEGROUND PIPING: 0X74 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXIES) AX) 04' PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE . UNDERGROUND PIPING: 0X74 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) XX) 04 PRESSURE l 1 05 SUCTION l 1 06 UNKNOWN 1 9 07 NONE II LEAK DETECTION 1 1 01 VISUAL ( ) 02 STOCK INVENTORY . ( 1 04 VAPOR SNIFF WELLS (K)l 05 SENSOR INSTRUMENT 1 1 06 GROU100 WATER MONITbRING WELLS 1 ) 07 PRESSURE TEST- ( 1 09 NONE ( 1 10 OTHER: III C4Em.TC'. Cn`!P2SITICN OF MATERIALS STORED IN UNDERGRLI'_IND CONTAt_ NFRS II YOU CHECKED YES TO IV•P YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION JRSENTLY PREVIOUSLY DELETE CASK fIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) LTORCD STORED ` rr 1 ) 01 ( ) 02 A , 03 111111J�11"I`�I I. I 1 1 01 ( ) 02 ( 1 03 III I ILI 11 1. 1 i" 1 _ _ -- 1101 1102 11031111111111111 l 1 O1 t 1 or. ..l 1 03 W I I I I I I 1 I I I , 1 , 01 ( , 02 1 , 031111IIIIIIILI l 1 01 O 02 03 1 ) 01 1 1 01 1 , 02 l ) 03 f101 1102 1 ) 03IIIIIIIII.IIII _ ) 01 ( 102 11031111111111111 5 CO!ITAINER LOCATED ON AN AGRICULTURAL FARM?� (. ) 01 YES T7{1X02 NO IS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. !PSOH FILING (SIGNATURE) PHONE W/ARCA CODE Flovd Wilsoli, O (79 wr-F,'t1F, OR LOCAL AGENCY USE ONLY 3M1122STPATINO AGENCY CITY CODE COVNTY CfI01) . )NTACT PIRSON PHONE W/AREA CODE •T[ OR VST INSI(CTION IN COMPLIANCE PEfMIT APPROVAL DATE TRANSACTION DAT[ LOCA' PERMIT ID R f 1 O1 1'[S 1 10[ NO C04-070185 - - PAGE 2