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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 GlzRUSBER LINED ( 1 02 ALKYD LINING l 1 03 EPDXY LINING 1 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> IES 07 UNLINED ( ) OB UNKNOWN 1 1 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT (Vr09 OTHER: t; S'S <br /> VI PIPING <br /> A. ABOVEGPOUNO PIPING: (k-l"­01 DOUBLE-WALLEDP7 PE 1 1 02 CONCRETE-LINED TRENCH 1 ) 93 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST �( 11 04 PRESSURE l✓1 05 SUCTION N 1 06 UNKNOWN ( 1 07 NONE. <br /> B. UNDERGROUND PIPING: (All"01 DOUBLE-WALLED�P��IPPF 1 1 02 CONCRETE-LINED TRE14CH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE (aT 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 O1 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS (105 SENSOR INSTRUMENT <br /> ( 1 06 GP.ONlo NATER MONITORING WELLS 1 107 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII C4"_ ICA--L- =S TION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED ES TO IV-F Y U ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 Dl ( ) 02_,_4"'l 03 <br /> ( 1 Ol (,_V-162 P3 <br /> f 1 Ol ( ) 02 l ) 3 <br /> l ) Ol ( ) 02 ( 1 <br /> ( 1 Ol ) 02 f 1 0 <br /> ( ) 01 ( J)2 f ) 03 <br /> ( l 01 ( ) 2 ( 1 03 <br /> ( 1 <br /> 01 ) 02 ( ) 03 <br /> 1 ) <br /> 01 ( 3 02 t ) 03 <br /> ( 1 O1 ;%( 1 02 ( ) 03 <br /> _ T$ CO'fTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (VT 02 NO _ <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> PEF NG ( D T E PHONE W/ARF SE O 9D i� yv• <br /> FOR LOCAL AGENCY USE ONLY f�K� <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE O. LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION D D # <br /> ( 1 <br /> 01 YES f 1 02 NO <br /> riSC04-077185 PAGE 2 <br /> ENVIROMENTAL HEALTH <br /> FERMITJSERMES <br />