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-- — STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 .101 RUBBER LINED ( 1 02 ALKYO LINING ( 1 03 EPDXY LINING 1 1 04 PHENOLIC LINING <br /> 1 1 07 ( 1 OS GLASS LINING, <br /> UNLINED 1 00 UKNOMR (,,1 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION 04 UI(NOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIE31 l 1 04 PRESSURE l 1 05 SUCTION 1 1 06 UNKNOWN ( 1 07 NONE <br /> S. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( 1 04 PRESSURE 0 05 SUCTION ( 1 06 UNKNOWN ( 1 07 HONE <br /> VII LEAK DETECTION <br /> F ( 1 01 VISUAL (/x 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> 1 1 06 GROLAID WATER MONITORING WELLS 1 1 07 PRESSURE TEST l 1 09 NONE 1 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> If YOU CMECRED YES TO IV-f YOU ARE NOT RE4U:RED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASA (If KNOWN). CHEMICAL TDO NOT USE COMMERCIAL NAME) <br /> . STORED STOR!O <br /> ( I O1 1 1 02 ( ) 03 I I I <br /> ( 1 O1 1 1 02 ( 1 03 <br /> 1 1 01 ( 1 02 1 ) 03 --:--�L <br /> l ) <br /> 01 ( ) 02 ( ) 03 <br /> 1 1 01 1 1 02 f 1 OS I <br /> 1 ) Ol 1 1 02 ( 1 03 <br /> 1 1 Ol ( 1 02 1 1 03 <br /> 1 1 01 1 1 02 1 1 OS I I <br /> 1 1 01 1 1 02 ( I 03 <br /> 1 1 <br /> al 1-1 02_( 1 03 I I <br /> IS CO'RAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES 1 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 /> PERSON FILING ION Gl.L� PHDNC WARFA CODE <br /> FOP. LOCAL AGENC- -USE ONLY <br /> 'AOY,LRSTPAT ING •GFNCY CITY CODE COUNTY CODE <br /> 'CONTACT P!PSCN <br /> PHONE W/ARCA CODE <br /> OAT! O• LASTNS7P SCT ION IN COMPLIANCE PERMIT APPROVAL OAT! TRANSACTION GATE LOCAL PERMIT IO R <br /> =, ( N GI YES r � 02 NO [-- -- <br /> „SC04-079185 <br /> PAGE 2 <br />