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CONTAINER CONSTRUCTION STATE ID NUMBER <br /> E. ! 1 '01 RUBBER LINED ) 02 ALKYD LINING ( 1 03 EPDXY LINING ! ) 04 PHENOLIC LINING ( } <br /> I 07 UOS GLASS LINING <br /> --. UNLINED UNKNOWN f --1-QV OTHER: �— ---� <br /> F. I 1 01 POLYETHLE14E WRAP 1 ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION X1 04 UNKNOWN ( 1 05 NONE — <br /> ( 1 Oft TAR OR ASPHALT { ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGPOUIO PIPING: ( 1 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH 1 ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UttOERGROUIID PIPING: C ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH K 03 GRAVITY <br /> {CHECK APPROPRIATE BOX(ES) ( T 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN <br /> VII LEAK DETECTION <br /> i 1 '01 VISUAL ► 0 CK INVENTORY { 1 04 VAPOR SNIFF WELLS 1 ) 05 SENSOR INSTRUMENT <br /> ( 1 06 GP.OLP40 R MOMTORING WELLS I I 07 PRESSURE TEST 1 I 04 NONE { 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 /> CVVFENTLY PREVIOUSLY DELETE CASs (IF KNOWN] CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STOPED <br /> f ) 01 ( ) Oz ( 1 03 1 l I f�l 11 I <br /> ( 1 01 ( 1 02 ( 1 0 3 —LJj = i , 11 LLLLu1 - <br /> ( ) 01 1 ) 02 r ) 03 I ! I I l l I P l f l I l <br /> 101 ( ' Q2 ( ' 03 X111 1 i l l l l _ <br /> { ) 01 ( ) 02 1 ) 03 <br /> ( 1 01 ( ) 02 { 1 03 <br /> 1 1 01 ( ) 02 [ ) 03 <br /> 1 ) 01 ( ) 02 { <br /> ( ) 01 ( ) 02 1 1 03 L <br /> I 02— ( I 03 <br /> I5 CO!ITAINER LOCATED ON AN AGRICULTURAL FARM? 1 101 YES { ) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT, <br /> PECSON F ING iSIGNATUPE --- PHONE W/AREA CODE ---_— - <br /> LL ' <br /> FOR LOCAL AGEN USE ONLY <br /> •;EtrCY 1 Jy' <br /> 1-cS7Y' COBE ICOUt:7 t' CODE <br /> IL <br /> CON7Ar_T _D_P rti C - --- --- --------V7� s <br /> [PHONE W/AOEA CODE <br /> DATE 0f LAST INSPECTION IN COMPLIANCE - _-` PERMIT-APPROVAL DATE TRANSACTION DATE -- <br /> LOCAL PERMIY ID R <br /> —24 t t C1 )ES f i 0@ NO <br />+15C04-071)185 <br /> PAGE 2 <br />