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0 0 <br /> STATE ID NUMBER <br /> CONTAINER CONSTRUCTION - <br /> E'. I l 01 RUBBER LINED t ) 02 ALKYO LINING t 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS.LINING <br /> (?Cl 07 UNLINED ( 1 08 UNKNOWN ( 1 09 OTHERS <br /> F. f ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING 03 CATHODIC PROTECTION ( 1 04 tJNKNOWNt 105 NONE ^ _ <br /> (y 06 TAR OR ASPHALT t 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROU140 PIPING: t 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINEO TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( 1.04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> Q. UNDERGROUND PIPING: t ) 01 0 LE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (r 04 PRESSURE ( 105 SUCTION ( 1 06 UNKNOWNt 1 07 NONE <br /> VII LEAK DETECTION <br /> t 101 VISUAL ( 02 STOCK INVENTORY t 1 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT <br /> t 1 06 GP.OU140 WATER Ma(ITORING WELLS t 1 07 PRESSURE TEST ( 1 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED I:N UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASS (IF KNOWN) CHEMICAL 400 NOT USE COMMERCIAL NAME) <br /> STORED STOPsO <br /> ! 1 01 ( ) 02 ( 1 03 <br /> ( I 01 t ) 02 t 1 03 U-L, f <br /> t ! 01_ O 02 ( 1 03 I I ( I I 1 1 I®� I I I <br /> ( 1 01 B ) 02 ( ) 03 <br /> t 1 01 f 1 02 f 1 D_��l <br /> t 1 01 t 1 02 t 1 03 <br /> t-) <br /> f 1 01— ( 1 02 f 1 0�3 <br /> f 1 01 -( ) 02 ( 1 03_ <br /> -a 1 01 _ t -)_02 ) 03 <br /> -01 — ( 1 02-- ( 1 03 <br /> H]J <br /> 311.1J 1_1_1_11 L L_-..----- --- - ---- <br /> IS CCATAINER LOCATED ON AN AGRICULTURAL FARM? ( / 01 YES t 1 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY A1t09 TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> rSIG VPE PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> q"41-:I rt�STa • °,.�r�`. p /`�� I'TTY CODE COUNTY CODE - -- - <br /> }CC'r'AC• a_�' N 5a /e-1 a e PHONE w/ACEA CODE <br /> .---- ----- <br /> OAT[ O' tq$7 INSEE TION �IN COMPLIANCE �PERMgT APpROVAt OATS TRANSACTION DATE LOCAL PERMIT IO C <br /> C1 SES r r 02 NO <br /> aiC04-0' 185 PAGE 2 <br />