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CONTAINER CONSTRUCTION STATE IO NUMBER <br /> rE. ( I 01 RUBBER LINED ( 1 02 ALKYD LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING 1 1 OS GLASS LINING <br /> 1 1 07 UNLINED 1)O OA UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f 1 02 VINYL (RAPPING 1 1 03 CATHODIC PROTECTION IXI 04 UNKNOWN 1 1 OS HANE <br /> _1 1 06 TAR OR ASPHALT 1 1 09 OTHER: <br /> VI PIPING <br /> r-- <br /> 'A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-MALLEO PIPE 1 1 02 CONCRETE-LINED TRENCH 1 ) 03 GRAVITY <br /> 1CHECK APPROPRIATE BOXES) 1 ) 04 PRESSURE ( 1 OS SUCTION ( 1 06 UNKNOWN 1X) 07 NONE <br /> IB. UNDERGROUND PIPING: l 1 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH 1 ) 03 GRAVITY <br /> _ECHE CK APPROPRIATE BOX(ESI (� ) 04 PRESSURE 1 ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> 01 VISUAL (/9 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) OS SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELL! ( 1 07 PRESSURE TEST l ) 09 NONE 1 1 10 OTHER: <br /> L _. <br /> II 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 /> CUORCNTLY PREVIOUSLY DELETE CASS (IF KNOWN, CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> I <br /> f 1 01 ( 1 02 ( 1 03 <br /> i I 1 01 1 1 02 f ) 03 I I <br /> ( 1 01 ( 1 02 f 1'03 <br /> ( 1 01 f 1 02 1 1 03 <br /> f; 1 1 01_ ( 1 02 ; ) 03 LL <br /> ( , 01 ( , 02 ( 1.03 - <br /> -( 1 01 1 ) 02 ( 1 03 I I I <br /> ( I <br /> 01 ( 1 02 ( ) 03 <br /> 1 1 O1 ( 1 02 ( 1 03 <br /> r <br /> L 1 1 01 ( ) 02 ( 1 03 <br /> I <br /> `13 CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES 02 ND <br /> !HIS FORM HAS BEEN COMPLETED IRA ER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PSON FILING ISIONATUREI PHONEW ARLA GOD! <br /> -- S3 <br /> FOR LOCAL AGENCY USE ONLY <br /> T <br /> I.OMINISTRATINO AO[NCY CITY COOS COUNTY CODE <br /> �CC-TACT PERSON PHONE W/AREA COOL <br /> :AT[ OF LAST INSF[CTION IN COMPLIANCE <br /> PERMIT APPROVAL DATE TRANSACTION DATE HOCA( P{RM27 ID R <br /> ( 1 O1 YES 1 1 OI HO <br /> t SC04-070]6' <br /> PAGE 2 <br />