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COHTAINER . CONSTRUCTIONSTATE ID NUMBER, <br /> E. ! al RUDeER LINED 1 1 02 ALKYD LINING ! `1 03 EPDXY LINING ( 1 04 PHENOLIC LINING I 1 05 CUSS LINING, <br /> ( 1 07 UNLINED (✓'j 08 UIII(IIOM1(FI ( 1 09 OTHER( <br /> F. C 1 01 POLYETHLENE WRAP C 1 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION (-f 04 UNKNOWN ( 1 OS NONE <br /> ( 1 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI ' PIPING ' <br /> ASOVE4. <br /> (CHECK OUND <br /> P RATE ( 1 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE 8OX(ES 1 ( 1 04' PRESSURE l 1 05 SUCTION ( 1 06 UNI(NOWN ( 1 07 "ONE <br /> b. UIIOERGROUND PIPING: <br /> ( ),,V DOUBLE-WALLED PIPE ( i 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> 1 CHECK APPROPRIATE DOMES) (✓� 04 PRESSURE ( 1 05 SUCTION ( 1 06 MIMO N { 1 07 NONE <br /> VII LEAK DETECTION <br /> 1 al VISUAL ( 1 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUIID NATER "ITORING WELLS (VI 07 PRESSURE TEST 1 1 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 REgU:REO TO COMPLETE THIS SECTION <br /> CUPFENTLY PREVIOUSLY DELETE CASm (IF KNOWN) <br /> STORED STORED CHEMICAL 100 NOT USE COMMERCIAL NAME) <br /> 1 1 01 ( i 02 f 1 03 <br /> ( 1 Oz ( 1 02 ( 1 03 1 I I <br /> ( i 01 ( 1 02 1 1 a3 <br /> 1 1 01 1 1 02 4 1 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> ( 1 01 i 1 02 ( 1 os <br /> 1 1 01 ( ) 02 C ) 03 <br /> ( 1 01 l ) 02 { 1 03 <br /> ( 1 01 i 1 02 1 1 03 <br /> 1 1 01 f 1 02 C .1 03 <br /> 13 CO'tTAIIIER LOCATEO ON AN AGRICULTURAL FARN? f I col YES (✓? 02 No <br /> iIs FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />'EfSO.4 F,iLLINC ISIGNATUF PHONEY/AREA CODE <br /> • •cel ."N _ j aft �aoK�(c�pe i 2 o 9, -- wl G 2- -7 F& <br /> OR LOCAL AGENCY✓�%�USE ONLY <br /> O�1irISTPaTIN� A,ENGY CITY CODE C_'_--- <br /> OUNTY CODE <br /> oNTACT a*coca <br /> PMOw WlARlA CODE <br /> ___l <br /> ATE 0/ tobST INS IN COT+PIIANCE PERMIT APPROVAI part TIrwMSaCTj(" parE 1GCAL PERMIT IO M <br /> 01 IES t 00 NO <br /> C04-0??185 <br /> PAGE 2 <br />