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0 STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED f ) 02 ALKYD LINING f 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f ) 0`1 POLYETHLENE WRAP ( 7 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( ) 05 NONE <br /> 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING= f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINEDTRF,L)S,kl l ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04' PRESSURE l ) 05 SUCTION ( 1 06 UNKNOWN 07 NONE <br /> B. UNDERGROUND PIPING: _7j!!�_01 $RUBLE-WALLED PIPE [ ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL ( ) 02 STOCK INVENTORY l l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS PRESSURE TEST ( 1 09 NONE l 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 CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> f ) <br /> 01 f l 02 ( ) 03 <br /> ( I <br /> 01 l ) 02 f ) 03 I I <br /> ( ) +01 ( ) 02 f ) 03 <br /> ( ) 01 ( 1 02 ( l 03 <br /> f 1 01 f ) 02 ( 1 03 <br /> t 1 <br /> 01 ( ) 02 f ) 0.3 <br /> ( ) 01 ( ) 02 [ ) 03 <br /> ( ) 01 ( ) 02 f ) 03 <br /> IS CO!7TAINER LOCATED ON AN AGRICULTURAL FARM? ( l 01 YES �. 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALT OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON - PRONE W/AREA <br /> ICN TUR ) CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADML) RATING,iN Y u GS CITY CODE COUNTY CODE <br /> I!= <br /> J /V) <br /> CONTACT PERASON PRONE W/AREC <br /> OT t4_1 -�/ / ( _ Q <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( 1 02 NO <br /> MSC04-070185 PAGE 2 <br />