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STATE IO NUMBER ' <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER LINED ( ) 02 ALKYO LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 OS-StASS LINING <br /> 1 ) 07 UNLINED ( ) OB UNKNOWN ( 1 09 OTHER: <br /> F. ( 2 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( ) 05 NONE <br /> 1?4 06 TAR OR ASPHALT 1 1 09 OTHER <br /> VI PIPING <br /> A. ABOVEGROUND PIPING 1 1 01 DOUBLE-NALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 00 PRESSURE " 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. Ut#OERGROUND PIPINGI ( ) 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE >4-05 SUCTION ( 1 06 UNKNOWN ( 107 NONE <br /> VII LEAK DETECTION <br /> ( 1 O1 VISUAL ( ) 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> 1 1 06 GROUND WATER MONITORING WELLS �4 07 PRESSURE TEST ( 1 09 NONE ( 1 10 OTHER- <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV•P YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASK (If KNOWN/ CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> ( 1 <br /> 01 ( 1 02 ( 1 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) OS I I I <br /> I ) 01_ t102 ( t03 � � � � � � Ll � � � � � <br /> 1 1 Ol ( ) 02 ( 1 03 <br /> 1 1 Ol ( ) 02 t 1 03 <br /> ( I Ol 1 1 02 ( ) 03 <br /> ( 1 01 1 1 02 O 03 1 I I <br /> I ) Ol I ) 02 ( 1 03 I I <br /> l ) Ol ( ) 02 ( 1 03 <br /> P <br /> " 1 ) O1 l 1 02 ( 1 03 <br /> IS CO!ITAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES 1 ) 02 NO <br /> c <br /> Dp - <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND. TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> aRSON FILING (SIGNATURE) PMO HE W/ARCA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY COD! <br /> CONTACT PERSON PHONE W/ARCA CODE I <br /> DATE OF LAST INSPECTION IN COMPLIA NC[ PERMIT APPROVAL DATE TRANSACTION DAT[ LOCAL PERMIT IO R <br /> .iSC04-070IBS PAGE 2 <br />