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.� STATE 10 NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. C 1'01 RUBBER LINED l 3 02 ALKYD LINING ( 1 03 EPDXY LINING l 1 04 PHENOLIC LINING ( 1 05 GLASS LINING - <br /> 1 1 07 UNLINED OB LMIK14OHN ( 1 09 OTHER: <br /> f. 1 I 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING 1 1 03 CATHODIC 'PROTECTION Qa_04 UNKNOWN ( 1 05 NONE <br /> f 1 06 TAR OR ASPHALT 1 ) 09 OTHER: <br /> VI PIPING <br /> - - <br /> a. ABOVEGP.OUIN PIPING: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIESI ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. LAVERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH I ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESIL 04 PRESSURE l 1 05 SUCTION ( 1 06 UNKNOWN 1 ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (%L_02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> M ) 06 GP,OU O ATER MONITORING WELLS 1 ) 07 PRESSURE TEST ( 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 ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 101 O02 ( ) 03III1111111111 <br /> 1 1 01 1 1 02 ( 1 031 1 1 1 1 1 1 <br /> ( 101 ( ) 02 ( ) 031111111111111 <br /> ( 1 01 t ) 02 ( 1 03 <br /> 1101 O02 ( 1031111111111111 <br /> i l l 01 ( 1 02 ( 1 03 <br /> 1 ) 01 ( 102 ( ) 031111111 111111 <br /> 1 ) 01 ( ) 02 ( ) 03 <br /> L <br /> 1 ) 01 O 02 ( 1 03 MI I I I I I I I l l l l <br /> 1101 ( ) 02 11031111111111111 <br /> 13 CONTAINERLOCATED ON AN AGRICULTURAL FARM? f 1 01 TES i 1 02 NO <br /> THIS FORM HAS BEEN OMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. I5 TRUE AND CORRECT. <br /> PERSON F l G IS GNgTUP PHO NC W/AREA CODF <br /> FOR LOCAL AGENCY USE ONLY <br /> •DY•II+I TPAT'N- AGENCY CITY CODE COUNTY CODE <br /> �c9Q�.ua.c - <br /> CON•AC P-P,CN PHONE W/AREA CODE <br /> -. 44CA .i <br /> DATE OF MAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION GATE LOCAL PFAMIT ID tl <br /> 1 1 01 YES f 1 02 NO <br /> ASC04-070185 PAGE 2 <br />