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STATE ID NUMBER e <br />CONTAINER CONSTRUCTION <br />E. ( 101 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( D 05 GLASS LINING <br />( ) 07 UNLINED (XJ 08 UNKNOWN ( l 09 OTHER: <br />F. ( 101 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN A 05 NONE <br />( ) 06 TAR OR ASPHALT ( D 09 OTHER: <br />PIPING <br />A. ABOVEGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) (>U 04' PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. UNDERGROUND PIPING tX 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH [ ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) pi 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />t ) 01 VISUAL t ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS Q<) 05 SENSOR INSTRUMENT <br />t ) 06 GROUI4D WATER MOFfITORING WELLS OeJ 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 />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />(D01 <br />O02 <br />(1031111111111111 <br />O01 <br />O02 <br />1) 03llllllflllill <br />t ) 01 <br />( ) 02 <br />( ) 03 <br />( l 01 <br />t ) 02 <br />t ) 03 <br />( ) 01 <br />t ) 02 <br />t ) 03 <br />t ) 01 <br />( ) 02 <br />f ) 03 <br />( D 01 <br />( ) 02' <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) Ol <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES ( ) 02 NO <br />PHIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />PE ON FILING (SIGNATURE) PHONE W/AREA CODE �e <br />LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br />,CONTACT PERSON PHONE W/AREA CODE <br />DATE OF LAST INSPECTION %N COMPLIANCE PERM&T APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br />( ) O1 YES C ) 02 NO <br />HSC04-070185 <br />PAGE 2 <br />