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STATE IU NUMBER <br /> CONTAINER CONSTRUCTION <br /> E'. ( 1 01 RUBBER LINED ! 1 02 ALKYD LINING ( 1 03 EPDXY LINING f 1 04 PHENOLIC LINING 1 1 05 GLASS LINING <br /> ( 1 07 UNLINED ("fl 08 UIIKNOWN ( 1 04 OTHER- <br /> F. ( 1 01 POLYETHLENE WRAP i ) 02 VINYL WRAPPING l 1 03 CATHODIC PROTECTION (`<1 04 (AIKNOWN 1 1 05 NONE - <br /> ( 1 06 TAR OR ASPHALT ( 1 09 OTHER= «- <br /> --- <br /> VI P' I'PING <br /> A. ABOVEGROUND PIPING= ( 1 01 OOUt3LE-WALLEO PIPE 1 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX{ESI ( ) 04 PRESSURE ( 1 05 SUCTION ( ! 06 UNKNOWN ( ) 07 NONE <br /> 8. UIIDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIESI 1 04 PRESSURE ( 1 05 SUCTION 1 1 06 UNKNOWN 1107 NONE <br /> VII LEAK DETECTION <br /> i I <br /> 01 VISUAL 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GP.OUT{D ATER MOffITORING WELLS ( 1 07 PRESSURE TEST ( 1 04 NONE ( T 10 OTHER. <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQU.RED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STORED J f <br /> ( 1 01 ( } <br /> 02 ( 1 0 3 )�f I I I ) Ll—I—L_LL — <br /> -{ ) OL 1 1 02 1 1 03 <br /> �LIL <br /> L p I ' I I I <br /> f ) <br /> 01`— ( 1 02 ( 1 03 <br /> { 1 01 ( ) 02 <br /> t 1 01 ( 1 02 f ) 03 f l I <br /> t 1 <br /> 01 ( ) 02 ( 1 03 <br /> 11 01� ( 1 02 1 1 03 1 <br /> 1-1 01 -I -1 02 { 1 03 <br /> 1 1 01 I 10 2 <br /> `_1 01 02 ( i 03 <br /> IS CC'ITAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 O1 YES 1 02 NO <br /> THIS FORM HA BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THF BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> r.c9C•1 FIIa`T <br /> � Z— PHONE WiAREA COOS <br /> 1 <br /> r <br /> FOP LOCAL AGENCY USE ONLY <br /> - --------- -------- <br /> ------ - ------ <br /> A •E�NC/ CIT'r' COD - jCOUN'TY CODE <br /> 1 -(t - conoga*.��r <br /> CO•07ACT r C^l <br /> PHONE W:AvGA CODE - - - - -- -- <br /> � <br /> KATE O; ',AST INSCECTION IN CO"PLIANCF � T <br /> LOCAL PERMIT ID 0 <br /> r I G1 SFS r 102 NO PERMIT APPVQVAI DATE TvAN$ACTION DATF <br /> .t,C04-O'r'S1R5 <br /> PAGE 2 <br />