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STATE ID NICER <br /> CONTAINER CONSTRUCTION <br /> O1 RUESER LINED ( 1 02 ALKYD LINING ( ) 03 EPDXY LINING [ ! 04 PHENOLIC LINING ( ! 05GLASS LINING <br /> { ) 07 UNLINED 1X1 06 LRZKNOWN I ) 09 OTHER: <br /> iF. [ ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING 3 03 CATHODIC PROTECTION (k) 04 UWNO)N ( ! 05 NON <br /> [ ) 06 TAR OR ASPHALT ( ) 09 OTHER* <br /> d PIPING <br /> ; �- ABOVEGROUND PIPING* ( 1 01 DOUBLE-WALLED PIPE E ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> a CHECK APPROPRIATE BOX(ES) I ) 04 PRESSURE t ! 05 SUCTION ( 1 06 UNKNOWN 07 07 NONE <br /> a, UNDERGROUND PIPING* ( ) O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> [CHECK APPROPRIATE BOX(ES) f1 04 PRESSURE 1 ) 05 SUCTION f ! 06 LR!(NDWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> I { 1 <br /> 01 VISUAL I/�) 02 'STOCK INVENTORY ( ! 04 VAPOR SNIFF WELLS ( ! 05 SENSOR INSTRUMENT <br /> { ) 06 GROUND WATER MONITORING WELLS ( ! 07 PRESSURE TEST l ) 09 NONE 1 ) 10 OTHER'- <br /> CHEMICAL <br /> THER* <br /> L._. <br /> VIII CH Mc eo Pas COMPOSITION O R RATE tD COMPLETE H STORED SECTION <br /> N UNDERGROUND CONTAINERS <br /> Ir YOU <br /> CUA PENTLY PREVIOUSLY DELETE CA$b (IF KNOWN) ' <br /> CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> tTOREO STOREO - <br /> { S ) <br /> 01 ( I 02 E ) 03 <br /> [ ) 0k l ! 02 1 ! 03 <br /> I - <br /> [ ! O1 ( ! 02 ( <br /> )'03 <br /> 1 <br /> 1 1 01 I ) 02 t 1 03� <br /> [ ) OI I ) 02 ( ) o!s <br /> E x ! 01 ( ! 02 ( ! 03 <br /> s ) 01 1 ) 02 E ! 03 1 I l <br /> 1 01 02 03 <br /> 01 ( ! 02 ( ) 03 L1 <br /> i ( 1 O1 _ ( 1 02 ( ) 03 <br /> EjSC�OMTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (A) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANDS TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT' <br /> . - - PHONE W/AREA CODE <br /> �nEpSON PILIMG (SIGNAT <br /> FOR LOCAL AGE Y E ONLY <br /> CITY CODE COUNTY COOL <br /> ADMINISTRATINO AGENCY R <br /> PHONE W/AREA CODE <br /> CNTACT !PERSON <br /> PPERMIT APPROVAL DATE TRANSACTION DATE <br /> ATE Dr LAST INSPECTION IN COMPLIANCE <br /> LOCA1 P!R!)IT I0 R <br /> { ) 01 YES l ) 02 NG <br /> - --�— PAGE E <br /> )15rG4-0701135 <br /> % <br />