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1� <br /> CONTAINER CONSTRUCTION STATE ID NUMBERE. ' <br /> i 1 01 RUBBER LINED 1 02 ALKYO LINING 1 1 03 EPDXY LINING I 1 04 PHENOLIC LINING (- I D5 GLASS LINING <br /> 1 07 UNLINED t 08 UJII:ItOWN 1 I 09 OTHER: <br /> F- f 1 01 POLYETHLEII£ WRAP ( 1 02 VINYL WRAPPING [ ) 03 CATHODIC PROTECTION i 1 04 UNKNOWN 1 ) _ � 4 <br /> 06 TAR OR ASPHALT t 1 09 OTHER: OS NONE <br /> vi PIPING --- ___-__-- <br /> A. ABOVEGROUND PIPING: t 1 <br /> (CHECK APPROPRIATE BDXIESI 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH -1 1 03 GRAVITY` --- --A_- <br /> ( J 04_PRESSURE 1,X 05 SUCTION f 1 06 UNKNOWN 1 1 07 t <br /> _ tONE <br /> B. <br /> WIDERGROU110PIPING: <br /> (CHECK APPROPRIATE BOXIE5) I J 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> - (CH1 1 04 PRESSURE 1 J 05 SUCTION ( ) 06 UNKNOWN f ) 07 NOME <br /> VII LEAK DETECTION <br />� I 1 01 VISUAL RC) 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS -f J 05 SENSOR INSTRUMENT <br /> {-1 OF GP.OLRID WATER 110)IITORING WELLS I 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL 'COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> _ IF YOU C.HECkED YES TO IV-F YOU APL NOT PEOV:REC TO CO"1Rl,ETE THIS SECTION <br /> CUPcERTLY PPEVrOUStY DELETE CASH (IF Y.NOWN) -_—' --�-- "--- <br /> STOPED STOPSO CHEMICAL (00 NOT USE COMMEPCIAL NAME ) <br /> 02 1 03 <br /> --- ,N- <br /> ' µ' 01 - ' 1 02 <br /> f 1 01----(-1 02 { ) 03 <br /> 1 1 01 1—I 02 t ) 03 Li.1LJ_[_LLi-LLL.I____-� - - -_---�-- -- _ - <br /> f- 1 01 i I 02 - I-1 03-.11-1-1-1_I-!_�. Ll__lJJ <br /> t 1 01 -�f 1 02.- -t_) 03 <br />�1`OI -t�l 02� <br /> I 1 <br /> 01 ---'_1_02_.-f_. ) 03- <br />[ f O1 f_) 02 ( ► 03 <br /> J <br /> f 1 01 ( I 02 f 11 03 <br /> H. <br /> 5 CC'JTAINER LOCATED ON AN AGRIGULTUP,AL FARM! _f_ 1 01 YES 1 I 02 NO <br /> IS FORM HAS OEEN COMPLETED UI(DER THE PENALTY OF PERJURY AND, TO THE BEST OF tlY KNOWLEDGE, IS TRUE AND CORRECT. <br />'_cSC•1 FiII.•J,^, - .^.IGNATUFCI <br /> PNONE W/AREA CODE ..._.__ <br />]P, LOCAL AGENCY USE ONLY <br />;):I�::aTASTIN3 n;ENCY ---"_-- <br /> CITY CODE -- — — �OVKTY CODE <br /> INTACT pcc50N <br /> PHONE W/APEA CODE <br /> TE Or LAST INSCECTION �IN COMPLIANCE PEPMIT APPROVAL OATS TRANSACTION DATE <br /> 1 01 IES t0; Np LOCAL PEQMlT ID A <br /> 04-07:1185 <br /> PAGE 2 <br />