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CONTAINER CONSTRUCTION STATE ID NUMBER <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING t ) 04 PHENOLIC LINING t ) 05 GLASS LINING <br />( ) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION t ) 04 UNKNOWN t ) 05 NONE <br />(LP -16-6 TAR OR ASPHALT t ) 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: (L)'O1 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: ( 41 O1 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) (, ) 04 PRESSURE (1-f 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( ) <br />01 VISUAL t ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 44'05 SENSOR INSTRUMENT <br />t ) 06 GP,OU14D WATER MO)(ITORING WELLS ( ) 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 CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />t)01 <br />t)02 <br />t) 03(IIIIIIIIIIII <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />t )01 <br />( )02 <br />( )03I I I I I I I I I I I I I <br />( ) O1 <br />( 1 02 <br />( 1 03 <br />t 1 01 <br />( ) 02 <br />t ) 03 <br />('01 <br />(l02 <br />('°LIIIIIIIIIIII <br />t ) O1 <br />( ) 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />( ) 03 <br />( ) O1 <br />( l 02 <br />t ) 03 <br />IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 TES (-Y--02 NO <br />CHIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br />PERSO!J FILING ^S NA�T�1!)'eMO <br />NE W/AREA CODE <br />FOR LOCAL r GENCY USE ONLY <br />ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br />CONTACT P=_FSON PHONE W/AREA CODE <br />DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br />( ) 01 YES f ) 02 NO <br />ISC04-070185 PAGE 2 <br />