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• • STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> r(. 1 1'01 RUDDER LINED ( ) 02 ALKYO LINING ( 1 03 EPDXY LINING 1 1 04 PHENOLIC LINING 1 1 OS GLASS LINING <br /> 1 1 07 UNLINED 1 1 OB UNKNOWN 1 1 09 OTHER: <br /> F. 1 1 01 POLVETHLE14E WRAP 1 1 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN 1 1 05 NOME <br /> ( 1 06 TAR OR ASPHALT 1 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLEO PIPE 1 1 02 CONCRETE-LINED TRENCH 1 ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIESI 1 1 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> B. UIt10ERGROUND PIPING: l 1 01 DOUBLE-NALLED PIPE 1 ) 02 C RETE-LINED TRENCH 1 1 03 GRAVITY <br /> ICHECK APPROPRIATE BOX(ESI l 1 04 PRESSURE l 1 05 SUCTION f ) 06 UNKNOWN 1 ) 07 NONE <br /> VII LEAK DETECTION <br /> l 1 01 VISUAL 1 1 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> 1 1 06 GROURO NATER MOt1ITORING WELLS 1 ) 07 PRESSURE TEST 1 1 09 NONE 1 1 10 OTHER: <br /> V11I CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> II YOU CHECKED YES TO IV-F YOU APC NOT RC4UIRC0 TO COMPLETE THIS SECTION <br /> CVPPINTtY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL 100 NOT USE COMMERCIAL MAKE : <br /> STOPED STORED <br /> 1 1 <br /> 01 ( 1 02 1 II 1 1 1 1 1 <br /> 1 1 Ol 1 1 02 ( 1 03 <br /> 1 1 <br /> 01 1 ) 02 1 1 OS <br /> l 1 <br /> al ( 1 02 ( 1 03I I I ' <br /> t l Ol ( 1 02 ( ) 013 1 1 1 1 1 1 1 1 1 I I I II <br /> ( 1 01 1 1 02 ( 1 03 <br /> t ) O1 1 102 1 ) 031111111111111 <br /> I I 01__ ` 1 02 ( 1 03 Ll I I I I I I I I I I I <br /> 1 1 Ol I ) 02 1 1 OS <br /> 1 1 01 —I 1 02—( 1 03 I I I <br /> IS CONTAUIER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 TES 1 1 02 NO <br /> HIS FORM HAS BEEN COMPLETED URIDER THE PENALTY OF PERJURY AND. TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br />•![SOv CIII.6 iSIGNATV[CI PHONE W/AREA CODE <br /> OP. LOCAL AGENCY USE ONLY <br />&D-fr+:S`pd i:r;❑ "ENZY CITY COO[ (COUNTY CODE <br /> PHONE N/&PCA CODE —_--- - <br /> ATE 0' LAST IN eICTI( IN COMPLIANCE P[RM2T APPROVAL DATETRANSACTION DATE LOCAL PERMIT I0 ■ <br /> 04-0?1165 l PAGE 2 <br /> i • <br />