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STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> 1 01 RUBBER LINED— f J 02 ALKYD LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING { 1 05 GLASS LINING ' <br /> I 1 07 UNLINED { ) 0$ UNKNOWN ( 1 09 OTHER: <br /> F. { 1 01 POLYETHLENE WRAP { ) 02 VINYL WRAPPING f ! 03 CATHODIC PROTECTION (�'l 04 UtWNOWN ( 1 05 ~ <br /> f 1 Ob TAR OR ASPHALT ( ) 09 OTHER: NONE <br /> A. ABOVEGPOU140 PIPING: 1 1 01 DOUBLE—WALLED PIPE 1 J 02 CONCRETE—LINED TRENCH { 1 03 GRAVITY <br /> iCHECK APPRQPRIATE BOX(E51 ( 1 04 PRESSURE ( ) 05 SUCTION d ) 0b UNKNOWN ( 1 07 NONE <br /> 0. UtIDERGROUND PIPING: i 1 01 DOUBLE—WALLED PIPE ( 1 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 04 PRESSURE ( 1 OS SUCTION 1 ) 06 IJNKkOWN [ J OT HONE <br /> VII LEAK DETECTION <br /> ( I O1 VISUAL OZ STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> f 1 OE GP.OUI{O WAT€R M011ITORING WELLS ( 1 07 PRESSURE TEST ( 1 4 <br /> — 9 NONE ( 1 10 OTHER: <br /> 'VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YCU CHECKED YES TO IV-/ YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURFENTLY PREVIOUSLY DELETE CAS" (IF KNOWN) <br /> STORED STO7;0 CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> 02 <br /> ( 1 01 f 1 02 { 1 03 U 1 i I f ��LLQ J 1 I 1 I I <br /> 02 <br /> 1 f ) 0311 f !I I <br /> f ! 01 t 1 02 <br /> ( I O 1 ( I 02 i 1 fl--��.�y� <br /> 11 01 1 1 02 ( 1 03 U — <br /> 01 1 02 0 <br /> ( 1 01 . ( ) 02 ( 1 03 <br /> ( ) 01- ( 1 02 ( ) 03 ' I fL ! I ��J <br /> I I -- <br /> �—+- 01 .Q2_—_ r 1 03��r� _.�_.1L_�1—[—L�—L.E�. _�------ `------ <br /> IS CC'ITAIHER LOCATED ON AN AGRICULTURAL FARM? 4 101 YES <br /> - f 02 NO <br /> -- -- - <br /> THIS FORM HAS RE_Ej COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> ---------------- <br /> GS .� FILINIAG, <br /> E p _ P ONE W/AREA CODE - --1 ---- <br /> _ � T Sp_h1f`111`W4`yam!'....- <br /> FOP. LOCALNCY USE ONLY T <br /> CI <br /> --- TYCOPE COUP-'Ty COOS <br /> r / <br /> pllC <br />} <br /> PONE W/4REA CODE <br /> DATE OF Le!:T INSCECTION 11N COQ—PLIANCE PEPMIT APPROVAL OATS Ta 4NSACTI(3N p4TF <br /> I4 I I CS 'ES 1102 NO �...--- _--- LOCAL PERMIT ID p <br /> AIC04-0 — <br /> PAGE 2 <br />