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00 00 CONTAINER CONSTRUCTION <br /> STATE IO NUMBER 00p00038917001 <br /> E' f ) 01 RUBBER LINED f J 02 ALKYD LINING <br /> {X) 07 UNLINED t ) 08 UNKNOWN <br /> [ ) 09 OTHERS EPDXY LINING ( ) 04 PHENOLIC LINING <br /> F. ( ) OT POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 05 GLASS LINING <br /> tX) 06 TAR OR ASPHALT f l 09 OTHER: C ) 03 CATHODIC PROTECTION <br /> ( ) 04 UNKNOWN { J 05 NOME <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: <br /> (CHECK APPROPRIATE sox(ES) ( ] 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH [ J 03 <br /> C J 04 PRESSURE f ] a5 SUCTION ( ) 06 UNKMOWN ( ) 07 NOME <br /> B. UNDERGROUt;D PIPING: GRAVITY <br /> (CHECK APPROPRIATE BoXfE8J f ] 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH <br /> (X) 04 PRESSURE f ) a5 SUCTION { J E UNKNOWN ( ) 07 <br /> NONE <br /> ( <br /> VII LEAK DETECTION 1 03 GRAVITY <br /> i J 01 VISUAL <br /> 06 GROUND(X) 02 STOCK IP{VENTORY <br /> ( ) WATER MONITORING WELLS ( ) 07 PRESSURE TEST <br /> ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> VIII ( ) 09 NONE ( ) 10 OTHER: <br /> CHEMICAL COMPOSITION OF <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT RMATERIALSqU jpEO STORED I <br /> `NTLY PPEI'ICUSIY QEIETE CAS# {IF =�iUSPED To COMPLETE THIS SECCTI UNDERGROUND CONTAINERS <br /> C�.:rp� <br /> SICKED STORED KNOWN) <br /> D1 oz <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> t ) ( J ( ) 03 <br /> ( ) <br /> 01 ( ) 02 t J 03 <br /> ( ) 01 ( ) 02 ( J 03 <br /> t ) O1 f ) 02 ( J 03 <br /> ( ) 01 t ) 02 ( ) 03 <br /> { ) 01 ( ) 02 f ) 03 <br /> t ) 01 ( ) 02 ( l 03 <br /> f ) 01 ( ) 02 It 1 03 <br /> It J 01 ( ) 02 C 1 03 <br /> ( ) 01 ( ) 02 ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> rs coKTAIMER LOCATED ON AN AGRICULTURAL FARM, ( ) 01 YES (X) 02 NO <br /> IS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TR <br /> E.O� (SIGNATURE] UE AND CORRECT. <br /> s✓� S PHONE W/AREA CODE <br /> 3R LOCAL AGENCY USE ONLY <br /> MINIS RATING G-NCY <br /> f ® l CITY CODE <br /> 1 <br /> NTACT R SON <br /> COUNTY CODE <br /> ' <br /> 2 � PHONE W/AREA CODE <br />'E OF LAST INSPECTION <br /> TN COMPLIANCE <br /> +( ) O1 YES f 1 02 NO REKNIT APPROVAL DATE <br /> TRANSACTION DATE LOCAL. rERMIT ID st <br /> 14-fl 70X35 llOtlSt85) <br /> PAGE 2 <br />