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STATE IO NUMBER s CONTAINER CONSTRUCTION E. ( ( 01 RUBBER LINED ( 1 02 ALKYD LINING l ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING XI 07 UNLINED ( 1 08 Ut)Y.NOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( D 02 VINYL WRAPPING ( D 03 CATHODIC PROTECTION t 1 04 UNKNOWN ( D 05 NONE ( 1 06 TAR OR ASPHALT ( Xi 09 OTHER: Fibersteel Coated Exterior /I PIPING R. ABOVEGROUND PIPING: (X ) 01 DOUBLE-WALLED PIPE ( D 02 CONCRETE-LINED TRENCH ( XX) 03 GRAVITY (CHECK APPROPRIATE BOX(ESI ( ) 04* PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( 1 07 N40NE B. UDDOERGROUND PIPING: 9( D 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( X) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE III LEAK DETECTION (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS (}() 05 SENSOR INSTRUMENT ( D 06 GROU110 WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( D 09 NONE t D 10 OTHER: IIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU ARE NOT REgUIREO TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CASR (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STORED (X ) of ( ) 02 c D 03 Waste ,automotive l ubr ci ti on oil ( 1 01 ( 102 ) 03IIIIIIIIIIIII t D 01 ( ) 02 C ) 03 ) 02 ( 1 03 ( ) u1 ( ) 02 ( D 03 ( 1 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( 103 ( 1 01 ( D 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 ( 1 01 ( 1 02 ( 1 03 e IS CO'ITAINER LOCATED ON AN AGRICULTURAL FARM? ( D 01 YES (X) 02 NO HIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AIM, TO THE BEST OF MY KNOWLEDGE*' 15 TRUE AND CORRECT. PERSON FILING (SIGNATURE) PHONE W/AREA CODE 2 ,Az (714) 851-2259 FOP. LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/ARCA CODE DA' `F LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IP R < 1 01 YES C ) 02 NO 1. SC04-070185 PAGE 2