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• STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 1'01 RUBBER LINED ( ) 02 ALKYO LINING t 1 03 EPDXY LINING I ) 04 PHENOLIC LINING t 1 05 GLASS LINING, <br /> ( 1 07 UNLINED ( 1 08 UNKNOWN ( 1 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC 'PROTECTION ( 1 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) t ) 04' PRESSURE l 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 1 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> t ) <br /> 01 VISUAL ( 1 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GROU140 WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE t ) 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 /> CUPCENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAM'_) <br /> STORED STORED <br /> ( ) <br /> 01 ( l 02 ( ) 03 I I I I I I I I I I I I I <br /> O 01 ( 1 02 ( 1 03 1 1 1 1 1 1 1 1 <br /> O 01 O 02 O 03 <br /> 1 1 01 ( ) 02 ( ) 03 ( I I I I I I I I I <br /> O 01 ( 1 02 O 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br />( <br /> 1 1 01 () 02 ( 1 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> ( ) 01 - ( ) 02 ( ) 03 <br /> t 1 01 ( ) 02 ( ) 03 <br /> O 01 ( ) 02 ( 1 03 I I I I I I I I I I I I I <br /> IS CC'ITAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND. TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> `PERSO•4 F L NG TS TUFE PHO E W/ARE CODE <br /> FOR LOCAL AG NCY USE ONLY <br /> tDn1r:T�3r�p q`TI�;J AGENCY Lo CITY �O� COUNTY CODE <br /> 'C014TACT c_ccON PHON W/ARE CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION GATE LOCAL PERMIT IO # <br /> ( ) O1 )ES ( ) 02 NO <br /> ASC04-079185 PAGE 2 <br />