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STATE ID NUMBER <br />vONTAINER CONSTRUCTION <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />b<l 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( 101 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION t ) 04 UNKNOWN K) 05 NONE <br />( ) 06 TAR OR ASPHALT t ) 09 OTHER: <br />PIPING <br />LEAK DETECTION <br />t ) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS !XC 05 SENSOR INSTRUMENT <br />t ) 06 GROUND WATER MONITORING WELLS (kl) 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 />( ) 01 <br />( ) 02 <br />( ) 03 1 <br />A. ABOVEGROUND PIPING: <br />(SC) 01 DOUBLE -WALLED <br />PIPE <br />( ) 02 <br />CONCRETE -LINED TRENCH ( <br />) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) <br />($6 04 PRESSURE ( <br />) 05 <br />SUCTION <br />( ) 06 UNKNOWN ( ) 07 <br />NONE <br />B. UNDERGROUND PIPING <br />(Y)^ 01 DOUBLE -WALLED <br />PIPE <br />( ) 02 <br />CONCRETE -LINED TRENCH ( <br />) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) <br />(>6 04 PRESSURE ( <br />) 05 <br />SUCTION <br />( ) 06 UNKNOWN ( ) 07 <br />NONE <br />LEAK DETECTION <br />t ) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS !XC 05 SENSOR INSTRUMENT <br />t ) 06 GROUND WATER MONITORING WELLS (kl) 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 />( ) 01 <br />( ) 02 <br />( ) 03 1 <br />( ) 01 <br />( D 02 <br />( D 03 <br />( D 01 <br />( ) 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />( l 03 <br />( ) 01 <br />4 ) 02 <br />( ) 03 <br />t I 01 <br />( l 02 <br />( ) 03 <br />( ) 01 <br />( ) 02' <br />( ) 03 <br />( ) 01 <br />( l 02 <br />E ) 03 <br />t ) 01 <br />( ) 02 <br />t ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />IS CC(TAINER LOCATED ON AN AGRICULTURAL FARM? t ) 01 YES ( l 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 FILIN^ (S GNw UPE) PHONE W/AREA CODE <br />ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br />CONTACT PERSON PHONE W/AREA CODE <br />DATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br />( ) 01 YES C ) 02 NO <br />H3C04-070185 PAGE 2 <br />