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• • STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. (- 1'01 RUBBER <br /> ILINED( 1 O8 2 ALKYO <br /> L(NIN09 ( I o3 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING, - <br /> I 1 07 <br /> 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING l 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> �. <br /> ABOVEGROUND PIPING: t 1 0 -WALLED PIPE ( 1 02 CONCRETE-LIMO TRENCH ( 1 03 GRAV TY <br /> (CHECK APPROPRIATE BOX(ES) ( 04- PRESSURE l 1 05 SUCTION t 1 06 UNKNOWN ( 1 07 NONE <br /> a. UIIDERGROURD PIPING' ( 1>04 <br /> LE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH l 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) <br /> ( PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> yII LEAK DETECTION <br /> t 1 01 VISUAL I 1 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> 1 1 06 GP.OU140 WATER MONITORING WELLS l 1 07 PRESSURE TEST l 1 09 NONE ( 1 10 OTHER= <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> II YOU CHECKED YES TO XV-I YOU ARE NOT REgUZREO TO COMPLETE THIS SECTION <br /> CUPSENTLY PPEVIOUSLY DELETE CAS• (IF KNOWNI <br /> CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> t ) 01 ( 102 03IIIIIIIIIIIII <br /> ( ) <br /> 01 ( 1 02 t 1 03 <br /> ( 1 01 ( ) 02 l ) 03 <br /> t 1 01 ( ) 02 ( ) 03 <br /> 1 1 01 O 02 t ) 03 I I I I I I I I I I I I I <br /> ( 1 01 l 1 02 ( 1 03 <br /> ` 1 1 01 O 02 O 03 I I I I I I I I I I I I <br /> 1 1 01 O 02 l 1 03 l <br /> LLL--01 ( 1 02 ( ) 03 <br /> 1 ) 01 O 02 1 03 I L I I I I <br /> IS CO'ITAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES Ml) OZ NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANDo TO THE- BEST OF MY KNOWLEDGE. IS TRUE ANQ-pORRECT. <br /> PH NE W/ REA CODE <br /> j�F!oSON FILING ISIGNA- F ) �V �D� -- -----'-- <br /> FOR LOCAL AGENCY USE ONLY — _—_ --- ---------- -- <br /> ----- —_--- <br /> COUNTY CODE <br /> (`,---a <br /> - 0`;I17ISTPSTIN3 A; .: <br /> ECY ITY COOS------ --� --- -------------_. _.- <br /> -- -- -------- <br /> PHONE W/AREA COOS <br /> CONTACT P!c^CN <br /> LOCAL PERMIT IO <br /> DATE O• LOST INSCECTION TIN COMPLIANCE PERMIT APPROVAL• DATE TRANSACTION DATE <br /> 1 101 IES 1 1 02 NO - <br /> - --- - - ---- -- _ PAGE 2 <br /> HSC04-071165 <br /> • i <br />