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0 0 STATE IO NUMBER CONTAINER CONSTRUCTION E. ( 1 '01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING f 1 04 PHENOLIC LINING ( 1 05 GLASS LINING ( 1 07 UNLItfED ( 1 08 UflKNONN ( 1 09 OTHER: F. ( 1' 01 POLYETHLENE WRAP f } 02 VINYL WRAPPING 03 CATHODIC PROTECTION ( 1 04 UtfKNOWN I ) 05 NONE f 1 06 TAR OR ASPHALT 1 1 09 OTHER- VI PIPING A. ABOVEGP.OUNO PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ! 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. U1IOERGROU2D PIPING ( ) 01 DOUBLE-WALLED PIPE l ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) i D4 PRESSURE ( 1 05 SUCTION i 1 06 UNKNOWN ( 107 NONE VII LEAK DETECTION ( ) 01 VISUAL ( 1 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUfD WATER MONITORING WELLS l l 07 PRESSURE TEST 1 ! 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 CUPPENTLY PREVIOUSLY DELETE CASK IIF KNOWN) CHEMICAL (DO NOT USE COMMEPCIAL NAME) STOPED STORED ( r 01 l 1 02 r 1 03 1 1 1 1 1 1 1 1 1 1 1 1 1 ( ) 01 ( r 02 1 1 13 ( 1 01 l 1 02 1 1 03 1 1 1 1 1 1i �LLLI i I 01 l ) 02 ( 1 03 I I I I I I I I I I 1 ) 01 C ) 02 ( 9 03 C 1 01 ( ) 02 ( ) 03 I — I 1 n1 ( ' 02 1 1 03 11 1 I l l l i l l l l l C 1 01 C ) 02 C ) 031 - 1t01 ( ) 02 11031111111111111 t 1 01 I l 02 1 1 03 IS C0-ITAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES C NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALT OF P URY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. P€ SON FILING (SIG V PHON W/ARE CODE — ------- --- �5 FOR LOCAL AGENCY USE ONLY I ADMIJ:ISTPATING AGENCY CITY C E F TY CODE AS CN ICO11TACy,P`_FS _ _ _ _ _.....___ __— IF _��— PHO N€ W iO�E DATE 0' LAST INS=ECT ION IN COMPLIANCE EPMIT APPROVAL OATC TRANSACTION DATE LOCAL PERMIT IO b ( ! G1 YES f 09 NO ,15C04-0?7185 PAGE 2