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0 <br />STATE ID NUMBER <br />CONTAINER CONSTRUCTION <br />O1 RUBBER LINED t Y 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( l 05 GLASS LINING <br />( 07 UNLINED ( D 08 U)(KNOWN t l 09 OTHER: <br />'F. t 101 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( D 03 CATHODIC PROTECTION ( D 04 UNKNOWN ( ) 05 NONE <br />( ) 06 TAR OR ASPHALT t ) 09 OTHER: <br />VI -`PIPING <br />A.;ABOVEGROUND PIPING: ( D 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04' PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. UNDERGROUND PIPING: t D 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH t D 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) f ) 04 PRESSURE ( D 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />t ) 01 VISUAL (?�) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS ( D 05 SENSOR INSTRUMENT <br />( ) 06 GROU)dD TER MONITORING WELLS ( D 07 PRESSURE TEST ( ) 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 />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE_ CASE (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />( D 03 <br />( ) 01 <br />( ) 02 <br />( D 03 <br />t ) Ol <br />( ) 02 <br />( ) 03 <br />t D 01 <br />( ) 02 <br />( ) 03 <br />( D Ol <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( ) 03 <br />( D 01 <br />( ) 02 <br />t ) 03 <br />! ( D 01 <br />( ) 02 <br />( D 03 <br />) Ol <br />( ) 02 <br />( ) 03 <br />If ) 01 <br />( ) 02 <br />( ) 03 <br />S CO'(TAIHER LOCATED ON AN AGRICULTURAL FARM? t ) 01 YES (Y)_02 NO <br />`HIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />�N <br />EPSON FILING (SIONATUPE) PHONE W/AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />,ADMINISTPATINa AGENCY CITY COOS COUNTY CODE <br />4 <br />CONTACT PERSON P HE /AREA CODE <br />S C G 81-�� <br />'DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO E <br />( ) 01 YES t ) 02 NO <br />ISC04-070185 <br />PAGE 2 <br />