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F <br /> >Tlt HUMBER <br /> CONTAINER CONSTRUCTION <br /> ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( l 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN t ) 05 NONE —— <br /> ( ) 06 TAR OR ASPHALT t l 09 OTHER: <br /> tI PIPING <br /> 4. ABOVEGROU140 PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY ) <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04' PRESSURE ( ) 05 SUCTION f ) 06 UNKNOWN ( ) 07 NONE —e--� <br /> 3. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE --� <br /> III LEAK DETECTION <br /> ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT —^ <br /> ( ) 06 GROU14D WATER MOt4ITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( l 10 OTHER: <br /> /III 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 /> IURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) i <br /> STORED STORED <br /> ( ) 01 t ) 02 ( T 03 1 1 '1 l I i Ii - <br /> -( ) <br /> 01 ( ) 02 ( ) 03 1-1_1.I 1 f H I I-- <br /> 01 <br /> .._01 -( ) 02 ( ) 03 1.HI I I H LI I I1 <br /> a <br /> ( 1 01 O 02 t ) 03 i I I I I I I I I wl I ( I--� <br /> ( ) 01_—( ) 02 ( )_0-3 �l_�11_jL __ ---- <br /> 01 1 02 03 <br /> t ) 01 ( ) 02 ( ) 0-1—L1_1_L1—l.LJ_ ---- <br /> ( 1 <br /> 01 _ _° 03 <br /> ___J_LI_LLll_ <br /> 01 02 03 <br /> iS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES ( ) 02 NO <br /> IIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />'ERSON FILINC. tSIGNATUPE) <br /> --- _— PHONE W/AREA CODE <br /> OR LOCAL AGENCY USE ONLY <br /> DMINISTPATING AGENCY CITY CODE --]COUNTY CODE <br /> ONTACT P:RSCN PHONE W/AREA CODE <br /> FATE OF LAST INSPECTION iN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID H <br /> ( ) 01 YES ( ) 02 NO <br /> C04-070185 ----- ----.._.� /� � ------------ <br /> PAGE 2 <br /> 2sN3'1 : L.4-Y t`3 Ltd., Q Tflf_it�tic <br /> _ 3H <br />