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• <br />CONTAINER CONSTRUCTION <br />• <br />STATE IO NUMBER <br />[. 1 101 RUBBER LINED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br />(/Q 07 UNLINED ( 1-08 UI(Y.NOWN ( 1 09 OTHER: <br />F. ( 1 01 POLYETHLENE WRAP l 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN 0<) 05 NONE <br />( 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( 1 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />S. UNDERGROUND PIPING: t ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) )() 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN t ) 07 NONE <br />VII LEAK DETECTION <br />( ) 01 VISUAL (V1 02 STOCK INVENTORY <br />( ) 06 GP,OU14D WATER MO((ITORING WELLS <br />l 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 07 PRESSURE TEST ( ) 09 NONE X 10 OTHER: /� <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />If YOU CHECKED YES TO IV -F YOU ARE NOT REQUIREO TO COMPLETE THIS SECTION <br />CUPOENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE <br />CAS" (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />1,01 <br />(102 <br />O03111111111111L <br />CITY CODE COUNTY CODE <br />( 101 <br />(102 <br />( )03(I <br />I (I I I I I I I I I <br />( l 01 <br />( 1 02 <br />( ) 03 <br />PHONE W/ARCA CODE <br />1 1 01 <br />( 1 02 <br />O 03 <br />I I I I I I I I I I <br />( 1 01 <br />( 1 02 <br />(' 03 <br />APPROVAL TRANSACTION DATE PERMIT IO " <br />( , 01 <br />( 1 02 <br />( ) 03 <br />-DATE — <br />l — -�IOCAI <br />( , 01 <br />( , 02 <br />( 1 03 <br />PAGE 2 <br />" 01 _ <br />(' 02 <br />(' 03 <br />LI l 1 I I I i I I I 1 I <br />1 1 01 <br />1 1 02 <br />l) 03 <br />1, 01 _- <br />(_l 02-- <br />( 1 03 <br />I I I I I I I I I I I I I <br />IS C0'1TAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES <br />02 NO <br />THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />__lv__-, + FILING (SIGNATUGE) vHONE W/AREA CODE <br />FOR LOCAL AGENCY <br />USE ONLY <br />AO,IN: 3704T 1 NG AGENCY <br />CITY CODE COUNTY CODE <br />CONTACT o:c,CN <br />PHONE W/ARCA CODE <br />DATE OF LAST INSCECTION <br />1-IN--COPLIANCE( <br />APPROVAL TRANSACTION DATE PERMIT IO " <br />0 <br />-1-02_ NO <br />-DATE — <br />l — -�IOCAI <br />.4SC04-070785 <br />PAGE 2 <br />