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0 STATE I0 NUMBER <br />CONTAINER CONSTRUCTION <br />E. ( 1 01 RUBBER LINED ( D 02 ALKYD LINING t ) 03 EPDXY LINING t ) 04 PHENOLIC LINING ( D 05 GLASS LINING <br />C 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP ( D 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( D 04 UNKNOWN ( D 05 NONE <br />( ) 06 TAR OR ASPHALT ( D 09 OTHER: <br />V -II PIPING <br />A. ABOVEGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE t ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK <br />APPROPRIATE BOX(ES) ( ) 04' PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. U' NOERGROUNO PIPING: ( 1 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) 4 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />t ) 01 VISUAL ( 2 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GP,OU) ATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( 1 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 />ICURRENTLY <br />( STORED <br />PREVIOUSLY <br />STORED <br />DELETE, CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />(D01 <br />O02 <br />O03IIIillllllill <br />( D01 <br />( )01 <br />t )03 <br />- ( 101 <br />( 1 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( ) 03 <br />D 01 <br />( ) 02 <br />( 1 03 <br />01 <br />( ) 02 <br />( ) 03 <br />1101 <br />(102 <br />O03IIIIIIIIIIIII <br />( )01 <br />( )02 <br />( )03 y <br />( 1 01 <br />( ) 02 <br />( 1 03 <br />t ) 01 <br />( l 02 <br />( ) 03 <br />'S CO!JTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES ( ) 02 NO <br />'HIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANO, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />;;'PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />ADMI)JISTPATING AGENCY n 4 <br />'CONTACT PERSON rlNCOMP�LIANCZ <br />bATE OF LAST INSPECTION <br />1 YES ( ) 02 NO <br />iSC04-070185 <br />PERMIT APPROVAL DATE ITRANSACTIVU DATE LCtAt PERMIT TO if ... , <br />