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STATE IO NUMBER l r <br /> CONTAINER CONSTRUCTION <br /> 1. 1 101 RUBBER LINED ( 1 02 ALKYO LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> 1x1 07 UNLINED ( 1 08 UNKNOWN. ( 1 09 OTHER: <br /> F. t l 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING l 1 03 CATHODIC PROTECTION ( 1 04 U1lKNOWN (%l OS NONE <br /> ( 1 06 TAR OR ASPHALT 1 ) 09 OTHER: <br /> VI PIPING <br /> A'. ABOVEGROUND PIPING: l 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES1 t ) 04 PRESSURE ( 105 SUCTION 1 ) 06 UNKNOWN ( 1 07 NONE <br /> S. U1IDERGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH GRAVITY <br /> (CHECK APPROPRIATE BOX(E51 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 O1 VISUAL (0 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> 1 l 06 GROUI(D WATER MO►IITORING WELLS l 1 07 PRESSURE TEST ( 1 09 NONE 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 /> CVRRENTLY PREVIOUSLY OELETE CASK (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( 1 02 ( ) 03 ( I <br /> O 01 ( 1 02 ( 1 03 <br /> ( 1 01 ( ) 02 11 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> ( 101 ( ' 02 O03 Illlllilll <br /> O01 O02 O03 � I11111111111 <br /> ( ) 01 l ) 02 ( ) 03 <br /> () 01 O02 ( ) 031111111111111 <br /> ( ) 01 ( ) 02 ( 1 03 LI 1 1 1 1 1 1 1 1 1 1 1 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> 101 ( ' 02_( ' 031 I l l l l f l l l l l l <br /> IS CO'ITAINER LOCATED ON AN AGRICULTURAL FARM? t 1 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNOER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PYA. LING IGN UFEI PHONE W/AREA CODE <br /> -_ - - -- -- - �a5-ZZl � T� --- <br /> FOP. LOCAL AGENCY USE ONLY <br /> °D"2W'TPaT •%`cN`y �C_Yqo 0 E COUNTY COOS <br /> CONT AL PrP;r PH NE W/A A COPE <br /> - -c- - - - -----_ --- --- ----- 70"1 --' - _�8 - <br /> DATE Of LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO R <br /> -- - --�--C1 NES ( 02 NO --._--- <br /> ASC04-011185 PAGE 2 <br />