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A STATE ID NUMBER 00000018096008 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( l 09 OTHER: F. ( l 01 POLYETHLENE WRAP i ) 02 VINYL 'WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( l 05 NONE ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( 1 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK, DETECTION [ ) OI VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT C ) 06 GROUND WATER MONITORING WELLS i ) 07 PRESSURE TEST ( ) 09 NONE i ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YCU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS#. (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL E ) STORED STORED d ) 01 ( 1 02 ( l 03 ( 1 01 ( ) 02 ( l 03 f ) 01 ( ) 02 ( l 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 C ) 03 C 1 01 ( ) 02 ( ) 03 C ) 01 ( ) 02 ( 1 03 ( ) 01 ( ) 02 ( ) 03 C ) 01 ( 1 02 ( 1 03 ( ) 01 ( 1 02 ( l 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO THIS FCRM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. l PERSCN FILING (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSCN PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PEP.MIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID t ( ] 01 YES ( ) 02 NC HSC04-470185 (IOf18.'85) PAGE 2