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STATE ID NUMBER CONTAINER CONSTRUCTION E. t 1 01 RUBBER LINED ( D 02 ALKYL) LINING t D 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING ( 1 07 UNLINED ( D 08 UNKNOWN t D 09 OTHER: F. t 1 01 POLYETHLENE WRAP ( D 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION t 1 04 UNKNOWN ( D 05 NONE ( 1 06 TAR OR ASPHALT ( D 09 OTHER: VI PIPING A. ABOVEGROU140 PIPING: t D 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH t D 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN DO 07 NONE B. tRIDERGROUND PIPING: (X) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH t D 03 GRAVITY `;(CHECK APPROPRIATE BOX(ES) (x) 04 PRESSURE ( 1 05 SUCTION t ) 06 UNKNOWN t D 07 NONE VII.;LEAK DETECTION VISUAL t ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS (X) 05 SENSOR INSTRUMENT fv1__06 GP,OUHD WATER MM41TORING WELLS ( ) 07 PRESSURE TEST t D 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 CASA (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STOREO V.) 01 t 1 02 t 1 03 I_I I I I I I I I I I I I t 1 01 O 02 ( 1 03 t_t_LLLL I I I I I I I t 1 01 ( ) 02 ( ) 03 1_-1 _lam t f01 t D02 ( ) 03I I 1 ! D 01 ( D 02 ( 1 03 t ) 01 ( ) 02 ( ) 03 O01 tD02 ( ) 011111111IIIIII ( ' 01 ` 102 ( ) 0g_l_LI I I I I ( I I I I I t ) 01 ( D 02 ( D 03 ( t ) 01 t 1 02 t ) 03_1 1 1 1 1 1 1 1 1 1 1 1 1 1S CO!ITAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (DG 02 NO �s THHIS FORM HAS BEEN COMPLETED U11DER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. tt :MER$ON FILING (SIGNATUFE) � PHONE W/%RE A CODE P�a� FOR LOCAL AGENCY USE ONLY 4AOMINISTPATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE s r -- !OATQ OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 4 ( ) 01 YES t 1 02 NO -SC04-070105 PAGE 2