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i <br /> STATE ID NUMBER <br /> CONTAIINER CONSTRUCTI�,< <br /> • 1E.-( ) 01 RUBBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING I ) 04 PHENOLIC LINING l ) 05 GLASS LINING <br /> ()k 07 LINLINLD ( ) 08 UI(KNOWN ( ) 09 OTHER: <br /> IF. ( ) 01 POLYETHLENE WRAP ( ) 02 V114YL WCZAPPI14G 03 CATHODIC FROTECTION ( ) 04 UNKNOWN (b 05 NONE <br /> i ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> IA. ABOVEGROUND PIP1,NG: ( ) 01 DOUBLE-WALLED PIPE ( ) 0' CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> ,B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY <br /> 1_(Ct{ECK APPROPRIATE BOX(ES) 0() 04 PRESSURE ( l 05 SUCTION ( ) 06 UNKNOWN ( ) 07 N014E <br /> VII LEAK DETECTION <br /> I ( ) 01 VISUAL ( 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> L ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE (x) 10 OTHER: �kL& <br /> VIII CHEMICAL• COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> ICURPEKTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL Nk:l! ) <br /> STCPED STOPED <br /> r _ <br /> O <br /> 01 O 02 i t .13 ( I l I I I I <br /> } ( I O1 O 02 ( 103 <br /> 1 1 <br /> 01 O 02 O 03F( I 01 ( ) 02 ( ) 03 <br /> C ) O1 ( ) 02_ ( ) 03 LLLL( j I i I I I - ------ <br /> - - <br /> ` 02 _ ( 1 .03 1 .1I __I-1LH 1.11 _-_ <br /> -- 1 <br /> O1 <br /> ( f ( ) 02 i ) 03 <br /> (_ ) <br /> 01 O 02 t ) 03 - ---- <br /> '_O <br /> 01 O 02 <br /> L ( 1 01 O 02 O 03 <br /> o t <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES Q�) 02 NO -- <br /> THIS rM HAS BEEN COMPLETED UNDER THE PENALTY BAF PERJURY ANDt TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> ( <br /> PSO NG (SIGNA R ) - PHONE W/AP.E CODE <br /> 3- `171 <br /> FOR LOCAL AGE Y USE ONL <br /> aDMIN STRhT AGENCY n CI CODE —— COUNT(' CODE F <br /> (CONTACT PEPS 1 lY�,• 4 PH NE W/AR A CODE <br /> !DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 1 ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 PAGE 2 <br />