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—J STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 BBER LINED ( ) 02 ALKYO LINING t 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 1 0"07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. t 1 01 POLYETHLENE WRAP 1 ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION f ) 04 UNKNOWN E'-Y65 NONE <br /> l 106 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE [ 1 02 CONCRETE-LINED TRENCH ( If 03 GRAVITY <br /> (CHECK APPROPRIATE BOMS) ( ) 04' PRESSURE ( 1 05 SUCTION f 1 06 UNKNOWN f 1 07 NONE <br /> B. UNDERGROUND PIPING: (UY61 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY — -- - <br /> (CHECK APPROPRIATE BOX ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UW140WN l 1 07 NONE <br /> VII LEAK DETECTION <br /> I (AVISUAL 1 1 02 STOCK INVENTORY [ ) 04 VAPOR SNIFF WELLS DCI 05 SENSOR INSTRUMENT <br /> tet-)-06 GP.OUtO WATER MONITORING WELLS 1 1 07 PRESSURE TEST f 1N O NONE l l 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 /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 <br /> 01 1 ) 02 ( ) 03 <br /> f 1 <br /> 01 t ) 02 ( ) 03 <br /> f 1 O1 f ) 02 f ) 03 _-- <br /> ( ) <br /> 01 E ) 02 ( 1 03 <br /> ( 1 O1 ( ) 02 l 1 03 <br /> 01 02 03 <br /> ( ) O1 f 1 02 f ) 03 <br /> E I <br /> 01 1 ! 02 E 1 03 I I I <br /> f l OS ( )_02 ( ) 03 I I I <br /> 1 ) 01 ( ') 02 ( ) 03 — — <br /> TS CONTAINER LOCATED ON AN AGRICULTURAL FARM? 1 1 O1 YES 1 a-fZ 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 LING SIO URE) <br /> DNI W/ARC 00[ <br /> WN - - -� <br /> FOR O ALAAGENCY US ONLY <br /> ADMINISTRATING AGENCY <br /> CITY CODE COUNTY CODE I <br /> CONTACT PERSON PHONE W/AREA CODE <br /> GATE OF LAST INSPECTION IN COMPLIANCEPCRMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO n 1 <br /> 1 1 01 <br /> YES 1 ) 02 NO — <br /> HSC04-070185 <br /> PAGE ? <br /> —. t <br />