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STATE ID NUMBER 00000054181001 CONTAINER CONSTRUCTION E. ( l 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING C ) 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( 1 01 POLYETHLENE WRAP t ) 02 VINYL WRAPPING E ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE i ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( ) 05 SUCTION C ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( J 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) C 1 04 PRESSURE (X) 05 SUCTION C ) 06 UNKNOWN t ) 07 NONE VII LEAK DETECTION E ) 01 VISUAL (X) 02 STOCK INVENTORY ( ] 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT C ) 06 GROUND WATER MONITORING WELLS ( J 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS YOU CHECI<ED 'YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION CUPPENTLY PP.EVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE CCMMERCIAL NAME ) STCPEO STOPED ( ) 01 { ) 02 ( ) 03 ( 1 O1 ( ) 02 ( ) 03 ( l 01 ( ) 02 t ) 03 - - ( 1 01 ( ) 02 ( ) 03 ( l 01 ( ) 02 t ) 03 ( 1 01 f 1 02 ( ) 03 ( l 01 ( J 02 ( ) 03 ( ) 01 ( ) 02 { ) 03 ( 1 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS 15 CONTAINER LOCATED ON AN AGRICULTURAL FARM? 1 1 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON /LING (SIGNATURE ) PHONE /W/AREA CODE FOR LOCAL AGENCY USE ONLY AOMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTICN A�COMPLYZANCE PERMIT .4PPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID t! ES ( 1 02 NC HSC04-070185 (10/18/85) PAGE 2