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STATE ID NUMBER CONTAINER CONSTRUCTION E. ( ) 01 BER LINED ( ) 02 ALKYD LINING t 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING ( W 07 UNLINED ( ) 08 UNKNOWN ( 1 09 OTHER: F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 03 GRAVITY —(CHECK APPROPRIATE BOX(ES) ( ) 04' PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: (v)-fl DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY (CHECK APPROPRIATE BOX(ES) l ) 04 PRESSURE ( 105 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( I.e01 VISUAL ( 1 02 STOCK INVENTORY l 1 04 VAPOR SNIFF HELLS ( ) 05 SENSOR INSTRUMENT � ( ) 06 GROUND WATER MONITORING WELLS ( l 07 PRESSURE TEST ( ) 09 NONE ( l 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 (DO NOT USE COMMERCIAL NAME) STORED STORED O01 ( ) 02 ( ) 03I O01 ( 102 ( ) 031111111111111 O01 O02 ( ) 031111111111111 ( 101 O02 ( 103IIillllltllll O 01 ( 1 02 O 03 O01 O02 ( 103 11111111111 _ 01 ` ' 02 ( � 0311I 01 ` 102 ( ' 03I O 01_ ( )_02 ( 1 03 � ( ) 01 ( ) 02 ( ) 63 1 1 1 1 1 1 11 11 1 1 I IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES ( LJ-ti NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON LING SIO UREI PHONE W/ARE ODE e- FOR OCAL AGENt-Y 'US9 ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATETRANSACTION DATE LOCAL PERMIT ID n ( ) 01 YES ( l 02 NO H3C04-070185 PAGE 2