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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. f 7~t)1 RU88ER LINED ( 1 02 ALKYO LINING t 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( 1 07 UNLINED t 1 08 UlAKNOWNt 109 OTHER: <br />�F. t 1 01-POLYETHLEHE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC 'PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE t 1 02 CONCRETE-LINEO TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE.BOX(ES) ( ) 04' PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> S. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH �1 03 GRAVITY <br /> I (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN t 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL ( 1 02 STOCK INVENTORY l 1 04 VAPOR SNIFF WELLS t 1 05 SENSOR INSTRUMENT <br /> t 1 06 GP,OUTA) WATER MONITORING WELLS t ) 07 PRESSURE TEST ( ) 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT RE@UIREO TO COMPLETE THIS SECTION <br /> CUPcENTLY PREVIOUSLY DELETE CASK (If KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STOREO <br /> O 01 O 02 O 03 I I I I 1 1 1 1 1 1 1 1 1 <br /> ( 101 ( 102 ( 1031111111IIIIII <br /> t ) O1 ( ) 02 ( 1 03 <br /> t 1 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> t 1 01 ( 1 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 103I1IIIIIII (._III <br /> I °1 _ O 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> 1 1 01 O 02 ( 1 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> IS CO'(TAINER LOCATED ON AN AGRICULTUP.AL FARM? ( 1 01 YES (xj 02 NO -� <br /> — <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANOP TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> PecSO•d FILING (SIGNATUCE ) PHO E W/AR A �CIODE p a <br /> FOR LOCAL AGENCY USE ONLY _ _ _ <br /> •DSI++I',TPnTI+G AGENCY s CITY COOS — COUNTY CODE <br /> - kS&i 3`1 <br /> CON-ACT =[,CN V PHONE WAVE,* OQ CE <br /> O �(�1 <br /> LOCAL PERMIT IO p <br /> - <br /> DATE OF LAST kfScECTIC IN COMPLIANCE PERMIT APPROVAi DATE TRANSACTION DATE <br /> t + MC1 YES t + 02 NO�_---- -_— <br /> ,(SC04-070185 L( PAGE 2 <br /> _...,...- ........., .. ... .. .. ..�. :.... a ..._ .:, .., .,,, .. <br />