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. . STATE IO NUMBER f s I o" 2 <br /> CONTAINER CONSTRUCTION <br /> E ( )(0I RUBBER LINED( ) 08 UNKNOWN LINING03 <br /> OTHER; EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 OS GLASS LINING <br /> 07 <br /> NED <br /> F ( ) 0LNE WRAP (())02 VINYL OTHER: l ) 03 CATHODIC PROTECTION ( ) 04 U10CNOWN l ) 05 NONE <br /> 1 06TAR ORASPHALT <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l 1 01 DOUBLE-WALLED PIPE l ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(E5) OFE04: PRESSURE 1 ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B ()CHECKR APPROPRIATE•BOX(ES) ( ( 0104 IPRESSURELEO PI05 SUCTION CON;R 006EUIKNOWNTRENCH 07l NONE) 03 GRAVITY <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL 05LU STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> l ) 06 GRON W TER MONITORING WELLS ( ) 07 PRESSURE TEST ( 1 09 NONE ( 1 10 OTHER: <br /> Vill <br /> YOU CHEMICAL <br /> r[s COMPOSITION <br /> POSIT)IO a OF OT REQUIRED <br /> COMPLETE <br /> STORED IS SECTION IDUNNDERGROUND CONTAINERS <br /> CHECKE <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> O <br /> 01 c ) 02 ( 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> l ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> f 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) OS <br /> ( ) 01 ( ) 02 ( ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES 1 1 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br /> PHONE W/AREA CODE <br /> PERSON FIIZ G ISIGNATUREI <br /> FOR LQAL AGENCY USE ONLY <br /> CITY CODE COUNTY CODE <br /> ADMINISTRATING AGENCY15 /� <br /> U,1 PHONE W/AREA CODE <br /> CONTACT PERSON <br /> f� 7 <br /> TRANSACTION DATE LOCAL PERMIT ID # <br /> DATE Of AST INSQPECTZON IN COMPLIANCE PERMIT APPROVAL DATE <br /> ,2 i0 ) 01 YES ( ) 02 NO <br /> / O v PAGE 2 <br /> riSC04-070185 <br />