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� STATE ID NIdiBER <br /> CONTAINER CONSTRUCTION 'Mr <br /> E. 1 1 01 RUBBER LIHEO ( 1 02 ALKTO LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING 1 ) 05 GLASS LINING <br /> 1 1 07 UNLINED 1)o OB UNKNOWN 1 ) 09 OTHER: '"ll�,, <br /> F. 1 1 01 POLYETHLEUE WRAP 1 1 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION l/L1 04 UMNOWN ( 1 05 NONE <br /> 1 1 06 TAR OR ASPHALT I 1 09 OTHER: •� I' <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 1 01 DOUBLE-MALLEO PIPE1 1 02 CON RETE-LIVED TRENCH 1 1 Ol GRAVITY <br /> (CHECK APPROPRIATE BOXIES) ( 1 04 PRESSURE l 1 05 SUCTION 1 1 06 UNKNOWN 1 1 07 NOISE <br /> B. IR IOERGROUIID PIPING: 1 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE l 1 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> 1 1 O1 VISUAL ( 1 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> 1 1 06 GP.OU110 WATER MOIIITORING WELLS 1 1 07 PRESSURE TEST ( 1 09 NONE IA/1 10 OTHER: <br /> .s;ice ww <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CMECMED YES TO IV-F YOU AVE NOT RE9V:RED TO COMPLETE THIS SECTION <br /> i <br /> CURRENTLY PREVIOUSLY DELETE CASK IIF KNOWN) CHEMICAL 100 NOT USE COMMERCIAL NAM!) <br /> STOPED STOP!D <br /> ( 1 01 ( N) 02 1 1 01 <br /> 1 1 01 ( 1 02 1 1 OS <br /> 1 1 01 ( 1 02 ( 1 03 <br /> 1 1 01 1 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 1 1 03 <br /> 11 01 ( 1 02 l 1 03 <br /> 1 1 01 ( 1 02 1 1 OS <br /> 1 ) 01 1 ) 02 ( 1 0 <br /> 3 <br /> 1 1 <br /> 01 1 1 02 1 1 03 <br /> 11 01 1 1 02 ( 1 03 <br /> IS C0.'I7AIIIER LOCATED ON A14 AGRICULTURALFARM? ( �OIYES �) 02O <br /> THIS FORMqAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> PCR504 LINO 1 NAT UP ��� PHDN�/ARCA COD[ <br /> F R LO AL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PECSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID R <br /> ( 1 01 YES 1 1 OE NO <br /> 1 <br /> HSC04-070155 PAGE 2 <br />