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• STATE I0 NUMBER CONTAINER CONSTRICTU ION E. 1 1 01 RUBBER LINED ( 1 02 ALKYD LINING 1 ) 03 EPDXY LINING ( 104 PHENOLIC LINING ( 1 05 GLASS LINING. 1 1 07 UNLINED ( 1 OB UNKNOWN ( 1 09 OTHER: F. ( 1 01 POLYETHLENE WRAP 1 1 02 VINYL WRAPPING 1 ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 105 NONE ( 1 06 TAR OR ASPHALT it 1 09 OTHER: VI PIPING _ A. ABOVEGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE i ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE l 1 05 SUCTION 1 1 06 UNKNOWN ( 1 07 NONE S. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCHy03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 105 SUCTION ( l 06 UNKNOWN ( l 074NE VII LEAK DETECTION ( ) 01 VISUAL 1 ) 02 STOCK INVENTORY 1 104 VAPOR SNIFF WELLS ( 05 SENSOR INSTRUMENT 1 1 06 GP.OU110 WATER MONITORING WELLS 1 1 07 PRESSURE TEST ( ) 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# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STORED 1 1 01 ( ) 02 ( ) 03 -�_W_-l�l ( 1 01 f l 02 f l 03 ( I I I LL�L1Ll - ( 101 ( 102 ( 03IIIIIIIIIIIII 1 , 01 ( 1 02 ( ) 03�L_I 1 I al ( , 02 l , 03 ( 1 01 f 1 02 f 1 03 ( I I I I I I I I I I 1101 f102 1103IIIIIIIIIIIII ( 1 01 1 , 02 ( ) 03_L_L ( 1 01 l , 02 ( , 03 1 1 01 ( 1 02 1 1 03 ( I I IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? l ) 01 YES 1 1 02 NO THIS 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 FOR LOCAL AGENCY USE ONLY _ ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT P`_PSON- -� -� --- --- PHONE W/AREA CODE OAT! OF LAST INSPECTION IN COMPLIANC! PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID R ( I 01 YES f 1 02 NO d5C04-071185 " PAGE 2