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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER LINED f 1 02 ALKYD LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( 1 07 UNLINED f ) 08 UNKNOWN 1 1 09 OTHER: UN <br /> F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION ( 1 04 KNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE I ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION 1 ) 06 UNKNOWN ( 1 07 NONE <br /> B. UIDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (XI 05 SUCTION ( 1 06 UNKNOWN f 1 07 NONE <br /> VII LEAK DETECTION <br /> l ) O1 VISUAL (x1 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS 1 ) 05SENSOR INSTRUMENT <br /> f ) 06 GROUIN) WATER M0t7ITORING WELLS 1 1 07 PRESSURE TEST 1 1 09 NONE 170 10 OTHER:Solt,61FX[IN65 <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQVCREC TC COMPLETE THIS SECTION <br /> CUPPENTIY PREVIOUSLY DELETE CASP IIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STOPED <br /> 1_) <br /> 01 <br /> -__1 ) 02 I ) 03 I 7 I <br /> L1LJ J—LI I I l , <br /> ( 1 01 ( 1 02 f ) 03 <br /> f 1 Ol_ f ) 02 f ) 03 ILII—)III_1IIH_.__LL�1__Ll� <br /> 1 1 01_ l 1 02 O 03 1 I I I I I _L <br /> I I I 7 — — ------- -- <br /> 1 1 Ol_ ( 1 02 �1_LULL�__LH1�_L_— <br /> I 1 01 ( ) 02_( , NJt '_ IW�JW WLLLLL----- -- ------ ---- ---- <br /> 1 1 al— 1 1 02 1 ) 0-L3-I I__I I I_I I I I I. I I 1 - --- <br /> 1-1 01_ - 1_1 02 ( ) 03_.L_t�7.�1lLLIJI ' J <br /> 1 1 Ol_ 1 1-02 1 ) 03J I I I I I I I I I I 1-I <br /> �f-1 Ol _( 1 02— ( 1 03 <br /> S CC'ITAINER LOCATED N A AGRICULTIMAL FARM? ( 1 Ol YES IXI 02 NO — - -- -- I <br /> 11HIS FORM AS FEN PLET 0 U70ER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. 1 <br /> o[cgpV FI N NATO 1 NON � / E <br /> FOR LOCAL AGE CY USE ONLY T <br /> ----------- <br /> +0"I14 ST�PLn/T IhT3/�4�:E�NC�Y�� CITY CODE COUNTY CODE <br /> jl ---ALS L'1lvRs'uw_ 7p <br /> d CONTACT PEFSON PHONE W/APEA CODE - — ---- -- -- <br /> -- - - -`T - <br /> GATE OF LAST INSPECTION IN COMPLIANCE PFPM;T APPROVAL DATE TRANSACTION DATE (LOCAL PERMIT IO R <br /> `__-- t ) O1 1E5 1 i 13 NO -1-- <br /> _— _..—. --_ <br /> ,1SC04-070185 <br /> PAGE 2 <br /> �J � <br />