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STATE ID NUMBER <br /> CONTAINER CONSTRUCTI(. - <br /> IE. ( Y 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LIN�NG ( ) 05 GLASS LINING - — <br /> ( 07 UNLINED ( ) 08 UIStNOWN ( ) 09 DTHF.R: <br /> IF. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ()0 05 NONE <br /> 1 1 ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> (----- - <br /> iA. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 C014CRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> I — <br /> IB. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) f � PRESSURE [ ) 05 SUCTION ( ) 06 UNKNOWN (..) 07 H011E <br /> VII LEAK DETECTION <br /> I ( ) 01 VISUAL (VATOER <br /> 2 STOCK. INVENTORY ( ) 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT <br /> L ( 1 06 GROUND MONITORING WELLS ) 07 PRESSURE TEST ) 09 NONE (x) 10 OTHER: Aet4 lzJ c�Q <br /> VIII CHEMICAL• COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CH'CY.ED YES TO lV-F YOU ARE NOT R:4UIP•ED TO COMPLETE THIS SECTION <br /> CLIGPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> r- <br /> i ( ) of ( ) 02 ( ) D3 — <br /> } ( ) O1 ( ) 02 ( 103I I I I I I I I 111 11 <br /> ( 101 O02 O03fIIIf IIIIIIII -- -- � <br /> �( ) 01 O 02 ( l 03 I I I I I I 1 1 <br /> C ' 01 02__( ' 03 LLLLLI i I I 1 1 I _ <br /> IIIIIIIII _; <br /> t ) 01 ( 1 02 ( 7 03 <br /> ( 2 01 ( 1 02 ( 1 03 <br /> i <br /> t ) O1 t ) 02 O03 LI <br /> — <br /> i l <br /> 01 ( ) 02 ( 1 03 <br /> 1 <br /> o — 1 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (x) 02 NO <br /> r <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY !OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> ( <br /> PEPSO LING (SIGNAT * PHONE W/AREA ODE <br /> 7 <br /> FOR LOCAL AGENC-Y, USE ON <br /> IADMINISTRATI AGENC)' CITYffD COUNTY CODE . <br /> aj)4k <br /> CONTACT PEP ON PHONE W/AREA 0 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT A.PPROVAL DATE TRANSACTION DATE IOCAI PERMIT ID # <br /> ` ( ) <br /> 01 YES ( ) 02 NO <br /> t(SC04-070185 PAGE 2 <br />