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STATE ID NUMBER <br />CONTAINER CONSTRUCTION <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />( ) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER <br />F. ( ) 01,EOLYETHLENE WRAP ( ) 02 VINYL WRAPPING (L-1 <br />03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE <br />( 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING (2' O1 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( )) 04' PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. UNDERGROUND PIPING ( U1 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (4)`05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( WbS SENSOR INSTRUMENT <br />( ) 06 GROU140 WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 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 REQUIRED TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />( ) 03 I I I I ( I ( I ( I I <br />( ) 01 <br />( 1 02 <br />( ) 03 <br />( ) 01 <br />i ) 02 <br />( l 03 <br />( ) O1 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES ( 2 NO <br />-HIS FORM HAS BEEN COMPL ED UNDER PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />PERSON FILING (SIGN ) PHONE W/AREA CODE <br />FOR LOCAL AGCY USE ONLY <br />ADMINISTP.ATING AGENCY CITY CODE COUNTY CODE <br />CONTACT PEFSON <br />DATE OF LAST INSPECTION IIN COMPLIANCE(PERMIT APPROVAL DATE <br />( ) 01 YES ( ) 02 NO <br />SC04-070185 <br />0 <br />PHONE W/AREA CODE <br />TRANSACTION DATE <br />0 <br />LOCAL PERMIT ID # <br />PAGE 2 <br />