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STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYO LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 OS GLASS LINING <br /> 1 07 UNLINED ( ) OB UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING l 7 03 CATHODIC PROTECTION f(yl 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT 1 ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 OOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE l 1 05 SUCTION f 1 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 7 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE Q() 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 Ol VISUAL ( ) 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS f 1 OS SENSOR INSTRUMENT <br /> ( 1 06 GP.OUI01 WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( 1 09 NONE (&) 10 OTHER:blel <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 PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> f�f <br /> 01 ( ) 02 ( ) 03 e <br /> l 1 01 ( ) 02 ( ) 03 <br /> ( l <br /> 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 1 ) 03 <br /> ( 1 O1 ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 1 ) 03 <br /> 1 1 01 ( ) 02 1 1 03 <br /> IS CO!1TAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES Y`) 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 SON FI 2NG (SIG AT G ) PHONE W/AREA CODE <br /> FOR LOCAL A ENCY US ONLY <br /> ADMINISTRATING AGENCY �j/� CITY CO E COUNTY CODE <br /> LTJ aut l7�lf ,w- fr777Z1G7` 'lj <br /> CONTACT PERSON P ONE AREA CODE <br /> PDB tpGA r '_�?o q z K z�oFs <br /> (DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT TO # <br /> II ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 PAGE 2 <br /> t �J <br />