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STATE IO Nll1'7BER <br /> CONTAINER CONSTRUCTION <br /> i. f 1'01 RUBBER LINED ( 1 02 ALKYO LINING 1 1 03 EPDXY LINING 1 1 04 PHENOLIC LINING ( I OS GLASS LINING <br /> 1 1 07 LAMMED 1 1 08 UNKNOWN 1 ) 09 OTHER: <br /> ►. I 1 01 POLVETHLE14E WO AP 1 1 02 VINYL WRAPPING I 1 03 CATHODIC PROTECTION 1 1 04 UIKHOWN ( 1 05 NONE <br /> { 1 Oh TAR OR ASPHALT 1 t 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUIO PIPING: I 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ! 04 PRESSURE l 1 OS SUCTION t 1 06 UNKNOWN 1 1 07 NONE <br /> B. LRIOERGROUIM PIPING: ( i 01 DOUBLE-MALLEO IPE I 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI { 1 04 PRESSURE 05 SUCTION ( 1 06 UNKNOWN i i 07 NONE <br /> VII LEAK DETECTION <br /> t 1 01 VISUAL (X 02 STOCK INV€NTORY i 1 04 VAPOR 5HIFF WELLS t 1 05 SENSOR INSTPUMENT <br /> 1 1 Oft GROUIIO WATER "1ITORING WELLS 1 1 07 PRESSURE TEST I 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 REQUIRED TO COMPLETE THIS SECTION <br /> CV&SINTLY PREVIOUSLY DELETE CASK tIF KNOWN) CHEMICAL IDO NOT USE COMMERCIAL NAME) <br /> STORED STORED { <br /> 11 01 ( 1 02 { I 03 <br /> 1101 1102 ( 103I111lllllllll <br /> 11 01 t 1 02 ( 1 03 L_l—ISL <br /> l 1 01 ( 1 02 t 1 03 <br /> i 1 01 1 1 02 f 1 03 <br /> ( 1 01 f 1 02 [ 1 03 <br /> 1 1 01 1 1 02 1 1 03 <br /> 1 1 01_ 1 1 02 —1 1 03 <br /> t 1 01 f 1 02 1 1 03 <br /> 02T6 1 1 03 1 C I f I C I 1 1 C C f l <br /> IS CO'ITAINER LOCATED ON AN AGRICULTUP.AL FARM? 1 1 01 YES i 1 02 NO v — <br /> HIS FORM A eAEN COMPLETED UttDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br /> F!cSO'+ SIGN47UrE f .. --- .W=— --- PHONE N/AREA COD[ --- - —�- <br /> OR LOCAL AGENCY USE ONLY <br /> •0`cl,r�;-oe 7l".�. •;E"•�r -- --LCITN CODE �COUNI, COoC <br /> Cp 'A_r v�rcrti PHONE W/AREA CODE <br /> DAT[ 0. (AST INSVECTION IN COMPLIANCE pERRIT A•RpOVAL DATE 1TRANSACTION DATE LOCAL PERMIT 10 ■ <br /> - - - - I I U1 NES 4 , 02 NO <br /> �— --- — —3--- -- — --- -- LL -- <br /> SC04-0"1115 PAGE 2 <br />