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STATE ID NUMBER <br /> CONTAINER 'CONSTRUCT t'tM <br /> 1 1 01 RUBBER LINED ( ) 02 ALKYD LINING. ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING (x* 05 GLA33 LINING <br /> I 1 07 UNLINED ( ) 08 UHKHOFIN f I 09 OTHER: <br /> l 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING l 1 03 CATHODIC PROTECTION ( 104 UNKNOWN (x$ 05 NONE <br /> 1 1 06 TAR OR ASPHALT 1 1 09 OTHER: <br /> I PIPING <br /> ABOVEGROUND PIPING) (x71 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(E51 Ex) 04' PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> UNDERGROUND PIPING' (01 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 1x3104 PRESSURE l 1 05 SUCTION 1 1 06 UNKNOWN 1 1 07 NONE <br /> II LEAK DETECTION <br /> ( 1 01 VISUAL 1 1 02 STOCK INVENTORY l 1 04 VAPOR SNIFF WELLS 75x$ 05 SENSOR INSTRUMENT <br /> 1 1 06 GROU107 WATER 10IIfdRING WELLS 1 ) 07 PRESSURE TEST ( 1 09 NONE ( 1 10 OTHER: <br /> L11 CHEMICAL, CO M,POETTTON OF MATERIALS STOPED IN U4PERGP.OUND rONT�INERS -, <br /> Iv YOU CHECKED YES TO IV-F YOU ARE NOT PE4UIRE0 TO COMPLETE THIS SECTION <br /> JRRENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL IDO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> I 1 01 ( D 02 .( 1 03 I_LLl I 1 lil' le`I:.I <br /> 1 1 01 l ) 02 ( 1 11 I I LU <br /> f 1 Ol f ) 02 f 1 03 <br /> "V <br /> ( 1 01 1 1 02 ( , 03 <br /> 1 1 01 f ) 02 f ) 03 <br /> ( ) 01 1 102 1 1, 031I. I ) I I <br /> ( 101 1 , 02 1' , 0 ) I <br /> 3II1.•1I. IfIIII _ <br /> 1 Ol ( , 02 ( 03_1_f_1 <br /> . 101 1102 ( I 03111111111. 1111 <br /> 1101 II02 ( 103IIIIIIII11111 <br /> S CONTAINER LOCATED ON.AN-AGRICULTURAL FARM?' 1 1 01 YES . 1x3: 02 NO <br /> 15 FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> !GSON FILING ISIONATURE) PHONE W/AR A C S <br /> Floyd Wilsgl` r 209-9W!R16 <br /> OR LOCAL AGENCY USE' ONLY V <br /> )MINISTPATING AGENCY CITY CODE COVNTf CODI),., <br /> INTACT PIFSON PHONE W/AREA CODE ^ <br /> •TE 01 LIST INSP'ECTION iN COMPLIANCE PERMIT APPROVAL GATE TRANSACTION DATE LOCAL'PERMIT,20 R <br /> -- - - ( II-01 YES ( ) 02 NO --_—_ <br /> v04-071185 - PAGE 2 <br />