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CONTAINER CONSTRUCTION STATE ID NUMBER <br /> E. (��<) <br /> BER LINED f ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 OS GLASS LINING <br /> UNLINED ( ) Oe lAOCNOHN ( ) 09 OTHER: <br /> F• ( } O1 POLYETHLENE WRAP I ) 02 VINYL WRAPPING <br /> 06 TAR OR ASPHALT ( ) 03 CA7HOpIC PROTECTION ( ) 04 <br /> ( 1 ( ) 09 OTHER: <br /> I1M(HpWN (� ) 05 NONE <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 <br /> (CHECK APPROPRIATE BOXlE31 01 DOUBLE-HALLE IPE ( ) 02 CONCRET <br /> ( ) 04 PRESSURE UE LINED TRENCH ( ) 03 GRAVITY <br /> 1 1 05 SUCTION f ) 06 UNKNOWN ( ) 07 NO <br /> B. UNDERGROUND PIPING: HE <br /> ( ( ) O1 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-L <br /> INED TR <br /> (CHECK APPROPRIATE 80X(ES) ( 1 04 PRESSURE 1 ) OS SUCTION f ) 06 UNKNOWN <br /> ----- 03 GRAVITY <br /> 1 ) <br /> VII LEAK DETECTION 07 NONE <br /> f l O1 VISUAL f 1 02 STOCK INVENTORY 11 04 VA <br /> ( ) 06 GROU((p WATER MONITORING WELLS 1 1 07 PRREESSUREFTESTLLS )109 05 SENOR INSTRUMENT <br /> J 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV•F YOU ARE NOT RlgUIRED t0 COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASK (IF KNOWN) <br /> STORED STORED `CIHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> ( I 01 ( ) 02 f ) 03 � � V�✓�� .,� <br /> 1 1 01 ( ) 02 ( 1 03 <br /> f ) Ol O 02 l ) 03 I I I I I I I I I <br /> ( ) <br /> 01 ( ) 02 f 1 03 <br /> f 1 01 ( ) 02 ( ) 03 I <br /> ( 1 01 ( ) 02 ( ) 03 1 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 3 <br /> ( ) 01 f 1 02 ( 1 03 <br /> 1 ) 01 f 1 02 ( ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 01 YES <br /> 1 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE ANO CORRECT. <br /> PE D` FI G (SIO NA TU �) <br /> vPHONE W/ARIA CODE <br /> FOP. LOCAL AGENCY USE ONLY /�f �� yCO� <br /> DADM NISTPATING AGENCY <br /> CITY CODE <br /> CONTACT PEPSON COUNTY C00!��_ <br /> -_ PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION <br /> I(N COMPLIANC! PERMIT APPROVAL DAT! <br /> f <br /> :COMPLIANCE, <br /> YES f ) 02 NO TRANSACTION DATE <br /> LOCAL PERMIT ID K <br /> SC04-070185 <br /> PAGE 2 <br />