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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 01,RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (Pf 07 UNLINED f 1 08 UNKNOWN ( 1 09 OTHER: <br /> 01 POLYETHLENE WRAP ( l V VINYL WRAPPING f 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> f ) 06 TAR OR ASPHALT (41'09 OTHER! El a-'SS <br /> VI PIPING <br /> A. ABOVEGROUND PIPING= ( O1 DOUBLE-WALLEDPIP ( ) 02 CONCRETE-LINED TRENCH 1 ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST l ) 04 PRESSURE ( SUCTION f 1 06 UNKNOWN ( ) 01 NONE <br /> B. UNDERGROUND PIPING: (14-101 DOUBLE-WALLED PI�PEE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( 1 04 PRESSURE (WrOS SUCTION l 1 06 UNKNOWN ( l 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL f 1 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS l 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER) <br /> VIII CHEMICAL ., TICN OF MATERIALS STORED IN UNDERCROUND CONTAINERS <br /> IF YOU CHECKED c <br /> ES TO IV- OU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED 14 <br /> f ) Ol ( l 02 ( 1 03 <br /> l l Ol l 1 ( ) 03 <br /> ( ) 01 ) 02 l ) 03 <br /> 1 1 01 ( ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> 1 ) 01 ( ) 0 ( e03 <br /> f ) el ( )/2 1 ) 03 <br /> f ) 01 ( 02 f ) 03 <br /> l ) 01 1 02 1 ) 03 <br /> 1 ) 01 1 02 ( ) 03 <br /> .LIS CONTAINER LOC TED ON AN AGRICULTURAL FARM? 1 1 01 YES (v 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 /> P N U. ) PHONE W`AREA C DE_ J D _ 666.6 6,w <br /> FOR LOCAL AGENCY USE ONLY 2V 5 LT/ <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DA E # <br /> 02 NO <br /> OEC 24 HOD <br /> NSC04-070185 PAGE 2 <br /> ENVIRUMENTAL HEALTH <br /> FERMIT/SERVICES <br />