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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> 1. 1-1x01 RUDDER LINED 1 1 OE ALKYD LINING l 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 OS GLASS LININGµ <br /> 1 1 07 UNLINED ( 1 00 UNKNOWN 1 1 09 OTHERL <br /> F. l 1 01 POLYETNLENE WRAP 1 1 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION 1 1 04 UNKNOWN 1 1 05 NONE <br /> l 1 06 TAR OR ASPHALT 1 1 09 OTHER: <br /> VI PIPING <br /> A. ASMOROU40 PIPING: 1 1 01 OOUOLE-WALLEO PIPE 1 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ESI l 1 04' PRESSURE l 1 OS SUCTION 1 1 06 U1NKlow ( ) 07 NONE <br /> 0. UNDERGROUND PIPING: I 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE OOX(ES) ( 1 04 PRESSURE ( 1 OS SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> 1 01 VISUAL 1 1 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> I 1 06 GROUO) NATER MONITOR IMG WELLS 1 ) 07 PRESSURE TEST l 1 09 NONE l 1 10 OTHER- <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV•F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPFENTLY PPEVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME( <br /> STOPED STOP!O <br /> 1 1 01 ( ) 02 ( 1 03 I I I <br /> ( 1 01 l 1 02 ( 1 03 I I <br /> 1 ) 01 ( 1 02 1 1 03 <br /> l 1 01 ( ) 02 ( ) 03 <br /> I ) 01 ( ) 02 ( ) 03 I I <br /> 1 101 ( 102 ( 103 <br /> 1 ) 01 ( ) 02 ( ) OS <br /> 1 1 01 ( 1 02 1 1 OS I I <br /> I ) 01 ( ) 02 1 ) 03 <br /> 1 ) 01 ( 1 02 ( 1 03 ( I I <br /> IS CO:RAINER LOCATED ON AN AGRICULTURAL FARM? l 1 01 TES 1 ) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE FEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> FCPS E IH SIGN UPC ( PNO N! W/AR[A CODE <br /> 2 _ �,o�- 97 /fid <br /> FOR LOCAL AGE CT-USE—ONLY <br /> F.—om IlII$TPATIND AGENCY CITY CODE COUNTY CODE <br /> ICO"TACi P ci-N .... — --_ __ __ — onO NE W.Vt. CODE <br /> I <br /> CAT O• LAST INSPECTION IN COnPLIANC! PERMIT APPKOV4l DATE T�M1S+1Cf-10" DAT[ UCCA" VIM(ST ID R <br /> / 1 O1 VE S 1 1 02 NO�— <br /> nSCOa-D?71 B5 PAGE 2 <br />