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�/ ✓ STATE IO NUMBER <br /> CONTAINER 'CONSTRUCTION <br /> E. ( 3 01 RUBBER LINED ( 1 02 ALKYD LINING t ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> I 1 07 UNLINED ( 1 OB UNY.11{lWN ( } 09 OTHER. _ <br /> 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( 1 05 NONE <br /> { ) 06 TAR OR ASPHALT ( 1 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f } 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(E5) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN t ) 07 NONE <br /> B. U}IDERGROUND PIPING= ( ) 01 DOUBLE-WALLED PIPE [ 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL ( 1 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROU14D WATER MONITORING WELLS ( ) 07 PRESSURE TEST Jp 09 NONE ( 1 10 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 /> CURFENTLY PREVIOUSLY DELETE CAStt (IF KNOWN) CHEMICAL IDD NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> [ ) <br /> 01 ( ) 02 ( 1 03 LI 1_._- <br /> ( ) 01 ( ) 02 [ ) 03 I I I I k <br /> ( 1 01 ( 1 02 ( 1 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( } 03 <br /> ( ) O1 ( 1 02 ( 1 03 <br /> ( ) O1 ( 1 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> LSC_�'_JAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X 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 /> PERSON FILING (SIGNATURE ) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTAC PERSON PHONE oW/AREA CODE <br /> Q <br /> GATE OF LAST INSKECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID V <br /> ( 1 O1 YES I ] 02 NO <br /> rISC04-079185 PAGE 2 <br />