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1 <br /> • • STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING l ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> ( ) 07 UNLINED (xl 08 UNKNOWN ( ) 09 OTHER( <br /> F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING [ 1 03 CATHODIC PROTECTION (')C1 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETELINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(E5) ( ) 04 PRESSURE I ) 05 SUCTION ( 1 06 KNOWN ( l 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (() 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL (6 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND ATER MONITORING WELLS ( ) 07 PRESSURE TEST ( 1 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REgUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 <br /> 01 ( ) 02 ( 1 03 <br /> ( l01 ( 102 1103 11111111 11i <br /> ( l <br /> 01 f 1 02 ( 1 03 <br /> l ) 01 l l 02 ( ) 03 <br /> ( ) <br /> al ( ) 02 ( 1 03 <br /> ( ) Ol ( ) 02 ( l 03 <br /> ( ) Ol f 1 02 ( l OS <br /> 1 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> f 1 01 ( ] 02 f 1 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (kJ 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br /> PER NC Is ) PHONE W/ARE C00 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCA) PERMIT ID # <br /> f 1 01 YES ( 1 02 NO <br /> HSC04-070185 PAGE 2 <br />