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CONTAINER CONSTRUCTION <br />E. t .1"01 RUBBER LINED t 1 02 ALKYO LINING t ) 03 EPDXY LINING <br />1 07 UNLINED t D 08 UNKNOWN ( D 09 OTHER: <br />STATE IO NUMBER <br />( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br />'F. 1 } 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( } 03 CATHODIC PROTECTION ( D 04 UNKNOWN 04 05 NONE <br />( ) 06 TAR OR ASPHALT ( } 04 OTHER: <br />VI PIPING <br />#A. ABOVEGROUND PIPING: ( 1 01 DOUBLE—WALLED PIPE ( 1 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br />1# (CHECK APPROPRIATE BOX(ES1 ( ) 04* PRESSURE ( 1 OS SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. UlIDERGROUNO PIPING: ( )1 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( 04 PRESSURE ( 1 05 SUCTION t ) 06 UNKNOWN t ) 07 NONE <br />VII LEAK DETECTION <br />1 01 VISUAL— ( 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br />1 1 06 GROU1(D WA ER 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 />CUPCENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE <br />CAS)) (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />( )01 <br />( )02 <br />( )03(1 <br />I I I I 11111 11 <br />() 01 <br />( 1 02 <br />( 1 03 <br />1 1 1 1 1 1 1 1 1 1 1 1 1 <br />t )01 <br />('02 <br />('031 <br />t ) 01 <br />( I 02 <br />( ) 03 <br />1 01 <br />02 ( D02 <br />( 031 <br />I I I IJ 1 1111 11 <br />t i 01 <br />( 1 02 <br />( 1 03 <br />t )01 <br />( )02 <br />t )031 <br />1111 L1 1111 11 <br />E►01_(-102 <br />()03LIIIIIIIIIIII <br />O1 <br />( D 02 <br />l ) 03 <br />L O 01 -- <br />(_ 1 02_ <br />O 03 <br />I I I I I I I I I I I l l <br />IS CO'(TAINER LOCATED ON AN AGRICULTUP,AL FARM? <br />( ) 01 YES ( A 02 NO <br />THIS FORM HAS BEEN COMPLETED UNOER THE PENALTY OF PERJURY ANDS TO THE BEST OF MY KNOWLEOGEs IS TRUE AND CORRECT. <br />P ON FILI4S fSIGNATUCEt ------ — PHONE W/AREA CODE _ -----------'-- <br />FOP. LOCAL AGENCY USE ONLY <br />AO" It!: S T P G Ti N5 AiE NC <br />CONTACT C_FSCN <br />IN COMPLIANCE <br />DATE Of LAST INSCECTION <br />( 01 SES <br />.45004-9?1185 <br />CITY CODE COUNTY CODE <br />PHONE W/AREA CODE <br />PERMIT APPROVAL DATE TRANSACTION DATE LOCM PERMIT IO d <br />PAGE 2 <br />