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CONTAINER CONSTRUCTION STATE tO NUMBER <br /> E. r )"01 RUBBER LIMED r 1 02 ALKYD LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( <br /> I I 07 UNLIUEO , 1 Oli U1IKNOWN 1 1 09 OTHER: ! 05 GLASS LINING <br /> 01 POLYETHLE14E WRAP { 1 02 VINYL WRAPPING 1 1 03 CATHODICPROTECTION f 1 04 UIJKNOWN <br /> 1 0h TAR OR ASPHALT 1 1 05 NONE - - <br /> I 1 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEG(CHECK <br /> PIPING: ( 1 01 OOUBIE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY , <br /> ICHECK APPROPRIATE BOXIEST 1 1 04 PRESSURE ( I OS SUCTION 1 1 06 UNKNOWN ( 1 07 NONE <br /> b. UAtDERGROU1tD PIPING: ( 1 01 DOUBLE-WALLS, (P,IPE 1 ) 02 CONCRETE-LINED TRENCH 1 i 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIESI f 1 04 PRESSURE Y OS SUCTION 1 1 06 UNKNOFRI 1 1 OJ NONE <br /> II LEAK DETECTION <br /> f 1 01 VISUAL 1 02 STOCK INVENTORY 1104 VAPOR SNIFF WELLS ( 1 05 SENSOR IHSTRUMENT 1 <br /> I 1 OF GP.OV10 NATER 1I001ITORING WELLS 1 1 07 PRESSURE TEST 1 1 09 NONE ( 1 IO OTHER: <br /> III CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQV:RHO TO CO"PLETE THIS SECTION <br /> CV09I NTLY "EVIOUSLY DELETE CAS■ (IF KNOWN) <br /> ITORED STORED CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> r 1 O1 { 1 02 1 1 03 I <br /> r l D1 y f 1 02 l i 03 �-Ll--I-( i <br /> 1 1 01 1 1 02 1 1 03 �L <br /> 11 01 ( i 02 c 1 03 <br /> 1 1 01 r 1 02 ( I 03 <br /> r l 01 t 1 02 ! 1 03 <br /> LJ I <br /> f I 01 ( 1 02 1 1 O3 <br /> 1 11 <br /> 1 01 f l 02 f 1 03 f I — -- <br /> 1 01 ( ! 02 f 1 03 LL <br /> f 1 01 ( 1 02 1— 1 03 <br /> rS CO'ITA111114 LOCATED ON AN AGRICULTURAL FARM? r r 01 YES 1 1 02 NO <br /> IIS FO M A EEN COMPLETED Ut10ER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT, <br /> SIL •� � sICNA7ucC _ —�� ..._�---- -- --- -- - -- ------- <br /> PHONE W/AREA CODE �///� <br /> aP. LOCAL AGENCY USE ONLY <br /> - - -�-- - -- -- -- �clr, CO., icov,:7. coaE <br /> PHONE W,AAEA CODE - <br /> A7'E U• LAST INSPECTION IN COMPLIANCE PERMIT APPROVAk DATE <br /> --_-- -_— <br /> Ii TRANSACTION DATE LOCAL PERMIT ID V <br /> -- '---1 C1 +ES 1 � O2 NO �--- - --' ------� <br /> PAGE 2 <br />