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Container Construction <br /> E. D o, Rubber Lined Do?Alkyd Lining Doo Epoxy Lining ❑on Phenolic Lining ❑os Glass Lining ❑m Clay Lining <br /> D o, Unlined Unknown D m Other. <br /> F. O o, Polyethlene Wrap 002 Vinyl Wrapping D m Cathodic Protection <br /> YL` Unknown D o5 None D os tar or asphalt D on Other. <br /> VI Piping <br /> A, Aboveground Piping: D o, Double-walled pipe D 02 Concrete-lined trench D os Gravity D 04 Pressure +*05 Suction <br /> [(Check) appropriate box(es) 1 D 05 Unknown D OT None <br /> B. Underground Piping: O o, Double-walled pipe D oz Concrete-lined trench D oa Gravity D 04 Pressure Wo5 Suction <br /> L(Check) appropriate box(es)] D oe Unknown D oT None ` <br /> VII Leak Detection <br /> Do, Visual ❑w Stock Inventory D w Tile Drain ON Vapor Sniff Wells D os Sensor Instrument <br /> D m Ground Water Monitoring Wells D 07 Pressure Test Doe Internal Inspection oe None <br /> ❑in Other: <br /> VIII Chemical Composition of Materials Currently or Previously Stored in Underground Containers <br /> If you checked yes to IV-F you are not required to complete this section. <br /> eunmlly "N" ly cd mk t Do NoI Use CoddrdE C l Name )Use add„conal P.nn'for more room, <br /> Gored stored CAS o OI known, <br /> D o, ❑02 <br /> ❑0t D02 <br /> Doi D 02 <br /> Is Container located on an Agricultural Farm? D0, Yes -R02 No <br /> Pnone wiaiea code <br /> Person Filing(Signature) <br /> f <br /> For Loral Agency Use Only <br /> oil COUNT <br /> AGENCY NAME <br /> ,NONE W/A,EA CODE <br /> CONTACT PEMON <br /> INSPECTION DATE 05T INSPECTION) PERMIT APPROVAL DATE PERMIT ID. NUMBER <br /> FOR STATE USE ONLY <br /> STA TE ID. NUM BER <br /> A¢wmmg 14,11, Cdonry Numbcl <br /> Da,e Recurved O m ❑02 G 09 <br />