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Container Construction <br /> E. O of Rubber Lined O 02 Alkyd Lining O 00 Epoxy Lining O w Phenolic Lining O os Glass Lining O oN Clay Lining <br /> O o-, Unlined 10oe Unknown O of; Other: <br /> F. ❑of Polyethlene Wrap 002 Vinyl Wrapping Om Cathodic Protection <br /> Unknown O os None O oft tar or asphalt O oo Other. <br /> VI Piping <br /> A. Aboveground Piping: O of Double-walled pipe O 02 Concrete lined trench O os Gravity O oa Pressure O oa Suction <br /> [(Check) appropriate box(es)] O off Unknown O OT None <br /> B. Underground Piping: O of Double-walled pipe O o2 Concrete-lined trench O os Gravity O Da Pressure Xoe Suction <br /> [(Check) appropriate box(es)] O off Unknown O oT None <br /> VII Leak Detection <br /> O of Visual O o2 Stock Inventory O D0 Tile Drain ON Vapor Sniff Wells O os Sensor Instrument <br /> ❑os Ground Water Monitoring Wells O w Pressure Test O oa Internal Inspection pl>_ None <br /> O to Other: <br /> VIII Chemical Composition of Materials Currently or Previously Stored in Underground Containers <br /> If you checked yes to IV-F you are not required to complete this section. <br /> euRmear WeAcilnlr Clmnlul Do Not Use Commercial Name (Use addilional No,for more room <br /> Stored aimed CAS N(11 known) <br /> O of O 02 <br /> [lot O 02 <br /> 0o 002 <br /> Is Container located on an Agricultural Farm? O of Yes 1Oe2 No <br /> Person Filing(Signature) Phone Wrarea MCC <br /> For Loral Agency Use Only <br /> AGENCY NAME CITY [011NTY <br /> CONTACT PERSON PHONE W/ATEA CODE <br /> INSPECTION GATE (IST INSPECTION) PERMIT 4PP ROYAL DATE PERMIT ID. NUMBER <br /> FOR STATE USE ONLY <br /> STATE ID. NUMBER Accounting Number County Number <br /> Dale Received ❑Of ❑02 003 <br />