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• STATE IO NUMBER /' 3 Q d Z <br /> CONTAINER CONSTRUCTION 9 <br /> E•. 1 1 01 RUBBER LINED 1 1, 02 ALKYD LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 1 1 07 UNLINED ) 08 UIO:NOWN 1 1 09 OTHER: -- <br /> f. 1 1 01 POLYETHLENE WRAP 1 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION t 04 UNKNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT 1 1 09 OTHER: 213- <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l 1 01 OOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE DOMES) ( 1 04 PRESSURE l 1 05 SUCTION 1 1 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST 1 1 04 PRESSURE CS SUCTION 1 1 06 UNKNOWN l 1 07 NONE <br /> VII LEAK DETECTION <br /> 1 1 01 VISUAL 1� 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> 1 1 06 GP.OIA TER MONITORING WELLS l 1 07 PRESSURE TEST l 1 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CMECKED YES TO IV•F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN/ CHEMICAL (DO NOT USE COMMERCIAL HAMEI l <br /> STORED STOPED <br /> ( I 1 01 1 1 02 ( 1 03 1�_L1J_LJ_ I <br /> 01 1 1 02 ( , 03 1 1 1 1 1 1 1 1 1.-LLL 1.-L11I - <br /> I I°1_ l I °2 _( 1 °31 <br /> ( 1 01 1 1 02 ( ( 03 I I I I I I I I I I I I I <br /> 1101 ( 102 11 03I111111111111 - - <br /> I 101 ( ) 02 , 0!-L1 I I I I I I 1 I I I I <br /> f 101 ( 102 f 103I � IIIIIIIIII' I' II _ --- <br /> I I °3_—_( 1 02 1 1 °3_L_I <br /> ( 1 01 —_ 1 _1_02 ( 1 03 I 1 <br /> I IL II II I I II IJJ.I I — -- — <br /> AJ <br /> �15 CC'ITAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES 1 102 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AIA, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> (PEP;C•1 f : l^. 4T f\1 PHONE W/AREA CODE <br /> - - - --- - --- �__�� -_(I66_gp�- - -- - <br /> FOP. LOCAL AGENCY USE ONLY <br /> �ap-{ •i;e:;��EyCT w� ICIT1CODE �COVNTr CODE <br /> I �/✓ ✓!/LF �U C N Lel c A L. 1�r�L� <br /> CO"_.AC, cEc^•IN - PHONE W/AREA CODE <br /> DATE OF LAST IN�STpPv TION IN COMPLIANC[ PERMIT APPROVAL OATC TRANSACTION DATE LOCAL PERMIT IO tl <br /> 7—V V 1. I CI SES L Ui NO — r <br /> N SC 04-07IIA5 - PAGE- 2 <br />