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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 11 01 RUBBER LINED ( ) 02 ALKYD LINING I ) 03 EPDXY LINING i 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( 1 07 UNLINED { 1 08 U)IY.NOWN d r 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( J 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN E 1 05 NONE <br /> (A1' 6 TAR OR ASPHALT ( 1 09 OTHER <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE—WALLED PIPE I 1 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> tCHECK APPROPRIATE BOX(ES) (11'04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UIIQERGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) I RESSURE ( ) 05 SUCTION [ ) 06 UNKNOWN t ) 07 NONE <br /> VII LEAK DETECTION <br /> itT�Oi VISUAL 1-1' 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS t 1 05 SENSOR INSTRUMENT <br /> t 1 06 GPOUi(D WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( 1 10 OTHER= <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL (00 NOT USE COMM€RCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( 3 02 ( J 03 <br /> ( 1 01 t 1 02 ( l 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> S 1 01 ( ) 02 1 ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( r 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( ! 02 ( 1 03 <br /> ( 1 <br /> 01 ( ) 02 ( J 03 <br /> ( i 01 i 1 02 ( } 03 <br /> ( ) <br /> 01 S i 02 ( 1 03 <br /> IS CQ'(TAINER LOCATED ON AN AGRICULTURAL FARM? E ) 01 YES ( 4J-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 /> PERSON FILING (SIGNAT +? / PHONE W/AREA COVE <br /> 'f <br /> FOR LOCAL AGAr-CY USE. ONLY <br /> ADMV.JISTPATING AGENCY CITY COO COUNTY CODE <br /> Lo Cd <br /> CONTACT P_ SOFT PHONE W/ARE CODE <br /> fC� <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 4 1 01 YES f ) 02 NO <br /> 8SC04-070185 PAGE 2 <br />