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M <br /> STATE ID NUMBER + <br /> CONTAINER CONSTRUCTION <br /> 01 RVB!!ER LINED ( 1 02 ALKYD LINING ! I *I EPDXY LINING [ ) 04 PHENOLIC LINING ( i OS GLASS LIMING, <br /> I 1 07 UNLINED (KI Od USIKSIOWN ( 1 09 OTHERt <br /> Ol POLYETHLENE WRAP [ 1 02 VINYL WRAPPING I 1 03 CATHODIC 'PROTECTION ( 1 04 UNKNOWN ! ) OS NONE <br /> ( 1 06 TAR OR ASPHALT ! 1 09 OTHER: el d <br /> r <br /> VI PIPING <br /> A. ADMOROUNI! PIPINGS [ 1 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TRENCH ( 1 03 6RAYITY �f laji ICHECK APPROPRIATE BOX(ES1 ( ) 04• PRESSURE ( 1 OS SUCTION i ) 06 UNKNOWN ! 1 07 NONEB. USIOERGROUND PIPING1 ( ) 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY ie <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 OS SUCTION [ 1 06 IIPRCNOWN { ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL 1 1 02 STOCK INVENTORY ! 1 04 VAPOR SHIFF WELLS [ 1 05 SENSOR INSTRUMENT <br /> ! 1 0b GROLA40 WATER MONITORING WELLS l ) 07 PRESSURE TEST 1 1 09 HONE ( 1 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-f YOU ARE NOT REAU:RED TO COMPLETE THIS SECTION <br /> CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> CURRENTLY PPEVIOUSLY DELETE CAS■ (If KNOWN) <br /> STORED STORED <br /> l ) 01 [ ) 02 t ) 03 <br /> 1 1 01 [ 1 02 ( 1 03 <br /> ( ) Ol l ) 02 ( ) 03 <br /> { 101 { 102 1 103 <br /> { 1 <br /> 01 ( 1 02 ( ) 03 <br /> ( 1 Ol ! 1 OZ ! 1 03 <br /> 1 1 01 1 ) 02 E ? 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> f 1 01 1 1 02 1 ) 03 <br /> 1 1 01 1 1 02 ( 1 03 <br /> 15 CO17AiNER LOCATED ON AN AGRICULTURAL FARM? t 1 01 YES (K 02 NO <br /> THIS FORM HAS BEEN COMPLETED LAMER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> PHONE W/AREA COOE <br /> EPSON F G (SIGNATUFE <br /> '� � Gf✓��---- CT Y1 / <br /> FOR LOCAL AGENCY USE ONLY ---- <br /> NY CITY CODE [OUNTY CODE <br /> IHISTPATINe AGENCY <br /> PHONE w/AREA CODE <br /> CONTACT P!rSON _:JP- <br /> DATE Or LAST INSPECTION IN COMPLIANCE - PERMIT APPROVAL DATE TRANSACTION DAT[ LOCAL PERMIT IO A <br /> S i 01 NES w_�_� --- -- <br /> _.__- PAGE a <br /> +4SC04-070185 <br />