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CONTAINER CONSTRUCTION STATE ID NUMBER 00000019740002 E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. [ ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( ) ( 1 05 NONE ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: 04 UNKNOWN VI PIPING A. ABOVEGROUND PIPING: E( ) DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ] 03 GRAVITY (CHECK APPROPRIATE DX(ES) 4 PRESSURE ( 05 SUCTION f ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: OOUB LE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXESPRESSURE fX) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( 1 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( 1 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) STORED STORED CHEMICAL (DO NOT USE COMMERCIAL NAME) ( 1 01 ( ) 02 ( ) 03 ( 7 01 ( ) 02 ( ) 03 ( ) Ol f ) 02 ( ) 03 f ) Ol ( 1 02 ( ) 03 f ) 01 ( ) 02 ( 1 03 f ) 01 ( ) 02 ( 7 03 ( ) 01 f 1 02 f ) 03 f ) 01 ( 1 02 f l 03 [ ) 01 ( 1 02 ( 1 03 ( 7 01 ( ) 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS ZS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO PHIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (SIGNATOR ^ PHONE W/AP.EA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE TATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE ( ) O1 YES f 1 02 NO LOCAL PERMIT ID # ;CO4-070185 (10/18/85) PAGE 2