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STATE 10 NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 , O1 RUBBER LIVED 1 / 02 ALKTO LINING 1 ) 03 EPDXY LINING ! 1 04 PHENOLIC LINING 1 1 OS GLASS LINING <br /> (%A 07 UNLINED ( 1 08 UIMNOWN 1 1 09 OTHER: <br /> F. 1 1 01 POLYETHLEUE WRAP 1 1 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION 1 1 04 UMNOWN 1Y� 05 NONE <br /> 1 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGP.OUIO PIPING: 1 1 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST l 1 04 PRESSURE lxl 05 SUCTION 1 1 06 UNKNOWN ( 1 07 NONE <br /> B. LRIDERGP.OUND PIPING: 1 1 01 DOUILE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE 17Q 05 S(CTION 1 1 06 UNKNOWN 1 1 07 NONE <br /> VII LEAK DETECTION <br /> _ 1 1 01 VISUAL 1 _1 02 STOCK INVENTORY 04 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> (-1 06 GP.OU110 WATER MIHIITORING WELLS 1 1 07 PRESSURE TEST ( 1 09 NONE ( 1 10 OTHER: <br /> VIII CIIEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQU:PEO TO COMPLETE THIS SECTION <br /> CUPRENTLY PREVIOUSLY DELETE CASP (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> 1 .01 --_t-'- 02 1 -1 03_x_ -- <br /> t-1 <br /> 01_----.1 1 02--f 1 03 <br /> 1 ) Ol_ 1-1 02 l 1 03 <br /> 1 1 01 .-- 1 1 02 1 I 03 <br /> 1 , Dl-- - 1. 1 D2-1 1 0--3-1__LJLL_1-1�-1_Ilj__H Ll 11 ------ <br /> i 1 01 ( I O2 1 1 03 I I I I I I I I I I I I — <br /> 1 1 Ol--- 1 ) 02 1 _1 O3 j I 1 1 I I 1 I 1 <br /> Ol ` 102 ( ' 03s LL I I I 11 <br /> 111�.._11�' IL_I I - <br /> ' 'D' _` '_02 03_LI 1 1 1 1 1 1 11I I -- <br /> u ( 1 D1--._----'-.'_.U2---_I 1 03 I I I I I I I I I I I I <br /> IS MITAINER LOCATED ON AN AGRICULT(R2AL FARM 1 1 01 YES 1x1 02 NO <br /> THIS FORM HAS BEEN COMPLETED DOER THE PENALTY OF PERJURY AND. TO THE BEST OF NY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PPPSON FIL143 [SIGNATURE PHONE W/AREA CODEg- �}/5-431-7200 <br /> - - -- - - - oil/ <br /> FOR LOCAL AGENCY USE ONLY <br /> AO�IN!STPATIN^. a.ENCY CITY CODECOVNTY CODE <br /> ------ <br /> _ L--_ <br /> CONTACT P!'SCN PHONE W/AREA CODE <br /> OATS OF LIST INSPECTIONIN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO P <br /> ---- ( ) <br /> 01 YES 1 ) 02 HO --- --- - <br /> L- - - --- - --� --- <br /> SC04-070185 PAGE 2 <br /> 'r <br />