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00 • 0 <br /> STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. f 1 01 RUBBER LINED ( ) 02 ALKYO LINING f ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> 1 ) 07 UNLINED ( ) 08 UNKNOWN 1 ) 09 OTHER: vX� <br /> F. ( ) Ol POLYETHLENE WRAP 1 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION / 04 UNKNOWN f 1 05 NONE <br /> (' ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING= l ) 01 DOUBLE-WALLED IPE 1 ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) t ) 04 PRESSURE 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UHOERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 104 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 O1 VISUAL (�1 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS 1 ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND W ER MONITORING WELLS l 1 07 PRESSURE TEST ( 1 09 NONE ( 1 30 OTHER: <br /> VIII 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 /> CURRENTLY PREVIOUSLY DELETE CASH IIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAM''-) <br /> STORED STORED <br /> 1 ) 01 ( ) 02 ( ) 03 I I V <br /> ) Ol O 02 ( 1 03 I I I I I I 1 1 1 1 <br /> 1 1 Ol O 02 l ) 03 <br /> 1 1 Ol ( 1 02 ( ) 03 <br /> f ) 01 ( ) 02 ( 1 03 I I I <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 I I I <br /> ( 1 01 O 02 1 1 03 LI I I I I I I I I I I I - <br /> ( ) Ol f ) 02 ( ) 03 <br /> f 1 Ol 02_I ) 03 I I I I I I I I I I I I <br /> IS MITAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 O1 YES 1 1 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> RF F I L I4G (SIG URE) PHONE W/AREA CODE <br /> a02� ao 4 �{GYQ4�s7 <br /> F O C A L AG'EN9 USE ONLY <br /> -DM In IS TP ATI NO 0.0E_0NCY I1jS CITY CODE COUNTY CODE <br /> CONTACT P-PSONPHONE W/A2RE0 COA DE <br /> _ <br /> DATE Oj LASi_ZNSPEO T_I ON IN COMPLIANCE( 02 NO PERMIT APPROVAL DATE — TRANSACTION DATE - LOCAL PERMIT ID M <br /> (1SC04-070185 (JQ 7 PAGE 2 <br />