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CONTAINER CONSTRUCTION STATE IO NUMBER 00000002264002 E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING f ) 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED- ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: (X) 05 NONE VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (CHECK APPROPRIATE BOX ( ) 03 GRAVITY BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (CHECK APPROPRIATE BOX(ES) . ( 1 04 PRESSURE (X) 03 GRAVITY 05( ) SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST ( ) 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) STCF,ED STORED CHEMICAL (00 NOT USE COMMERCIAL NAME) (X) 01 ( ) 02 ( ) 03 LUBRICATING OIL (X) 01 f ) 02 ( ) 03 SEDIMENT AND SLUDGE ( ) 01 ( ) 02 ( ) 03 ( ) O1 ( 1 02 ( 1 03 ( 1 01 ( ) 02 ( ) 03 j f ) 01 ( ) 02 t ) 03 ) ( ) O1 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 (. ) O1 f ) 02 ( ) 03 f ) Ol ( ) 02 ( l 03 Ll * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON LING (SIG TR n PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE TE OF LAST INSPECTION O1 YES 02 NO TION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE ( ) ( ) LOCAL PERMIT ZD # 10185 (10/18/85) PAGE 2 0