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CONTAINER CONSTRUCTION STATE ID NUMBER <br /> F( ) <br /> RUBBER LINED !(' ) 02 ALKYD LINING f 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 07 UNLINED � 08 UNKNOWN f ) 09 OTHER:POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION �(� 04 UNKNOWN ( ) 05 NONE <br /> O6 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04' PRESSURE ( ) 03 GRAVITY <br /> ( ) 05 SUCTION f 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: I ) 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (�C) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) O1 VISUAL f ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( 1 O6 GP,OUN0 WATER MONITORING WELLS ( ) 07 PRESSURE TEST (k 1 09 NONE f ) 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 CAS# (IF KNOWN) <br /> STORED STORED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> ( ) 01 ( ) 02 ( ) 03 I I I <br /> ( 1 Oi ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> l ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 f ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( 1 O1 f ) 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> f ) 01 l ) 02 ( l 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES 1 )=02 NO <br />'HIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON LINGI <br /> IIGNA 7 PHONE W/AREA CODE <br /> / v Z- 7 D <br />:OR LOCAL AGENCY USE ONLY <br /> 4DMINISTRATINO AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON <br /> PHONE W/AREA CODE <br />)ATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> f ) <br /> 01 YES ( 1 02 NO LOCAL PERMIT ID # <br /> 5C04-070185 <br /> PAGE 2 <br />