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I STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> 01 RUBBER LINED 1 1 02 ALKYD LINING 1 1 03 EPDXY LINING 1 1 04 PHENOLIC LINING 1 1 OS GLA n,LINIM <br /> l 1 07 UNLINED ( 1 OB UNKNOWN 1 1 09 OTHERS <br /> O1 POLYETHLEHE WRAP ( 1 02 VINYL WRAPPING 1 1 OS CATHODIC PROTECTION 1 1 04 UNODIN ( 1 OS HONE <br /> 1 1 06 TAR OR ASPHALT 1 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUO PIPING: 1 1 01 DOABLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH 1 ) 03 GRAVITY <br /> (CHECK APPROPRIATE BO%IESI l 1 04 PRESSURE ( 1 05 SUCTION / ) 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: 1 1 01 DOUBLE-WALLED MPIPE f 1 02 CONCRETE-LINED TRENCH 1 1 01 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST 1 1 04 PRESSURE T CS STICTION 1 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETEECTION <br /> 1 1 01 VISUAL1�1 02 STOCK INVENTORY 1 1 04 VAPOR SNIfF WELLS 1 1 05 SENSOR INSTRUMENT <br /> 1 1 06 GROU01MATER MUIITORING WELLS 1 1 07 PRESSURE TEST 1 1 09 NONE f KI 10 OTHER= <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CNCCkEO YES TO IV-F YOU ARE NOT FCOU:RED VC CO"LETE THIS SECTION - <br /> CURRENTLY PREVIOUSLY DELETE CAS• IIF KNOWNI CHEMICAL (00 NOT USE COM/ERCIAL NAME) <br /> STORED STORED , <br /> 1-1 01 -_I 1 02 1 1 03 I_I I I ' I I I I I 1 1 1 -- -- -- <br /> Lyu�Ll I 1 I_LL_ <br /> -( 1 01 - ( 1 02 ( 1 OS u�I I I I I I I <br /> 1 1 Ol f l 02 I 101 I I I I I I u._1-_L1_.1.�- <br /> 1 1 01 O 02 l 1-03 1 1 1 1 1 ` <br /> 1 1 Ol---f 1 02-_( ) 011I�I� l-LI_.WLlf------ ----- <br /> 1 1 01 1 1 02_1 , DWJ HWH <br /> I..__ --- ------------------ <br /> . ( i 01--- 1 1 02 1 _, 03 1 1 1 1 1 1 1W_j I - --- -- <br /> ( 1 01_- -_-1 _1 02_--'_ ' 01WLL11_IW_LL_ <br /> ' ' Dl '-' 02 ` '03.-L1 I f I I I I I W1WJ <br /> 1 01 ( 1 02- ( 1_03 <br /> 'IIS CC'ITAINER LOCATED ONAN AGR ICUITUP.AI FARM? 1 I O1 TES-/_ 02 NO — — - <br /> L <br /> THIS FORM HAS PEE C PL ED UIDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. I5 TRUE AND CORRECT. <br /> 1 <br /> NAT E ) <br /> FOP. LOCAL AG NCV USE ONLY <br /> C I ::STPe tI n� •;=N�y CITU CODE - -- ICOUN.TY CODE <br /> 5,d+ ICSON lu 191L_ P4C7tE cLL Lt�1C <br /> I'COv TwCT PEPSON PHONE W/AREA CODES <br /> -b//�L1��Y�'',p�_,Y--ll/l'/��LIY�{�dnL <br /> 10.77 <br /> E D• LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID <br /> Ol I[S 1 OZ NO - <br /> a1co4-o;ales <br /> PAGE 2 <br />