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`! STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER LINED ( ) 02 ALKYO LINING ( 1 03 EPDXY LINING f 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> 1 1 07 UNLINED 08 UNKNOWN ( 1 09 OTHER: <br /> F. ( I 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING tV-03 CATHODIC PROTECTION04 UNKNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE ( 1 05 SUCTION 1 1 06 UNKNOWN O() 07 NONE <br /> B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE 14 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL On 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> 1 ) 06 GROUND ATER MONITORING WELLS l ) 07 PRESSURE TEST ( ) 09 NONE l 1 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 PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 1101 O02 O03IjIIIIIIIIIII <br /> ( 1 <br /> 01 l ) 02 ( 1 03 <br /> ( 1 01 ( 7 02 ( ) 03 <br /> l 1 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( 1 03 <br /> t ) 01 t ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> 1 ) 01 ( ) 02 ( ) 03 <br /> 1 ) O1 ( ) 02 ( ) 03 <br /> 11 O1 f 1 02 ( 1 03 <br /> IS C(PNTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES ( 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 /> PERSO. FIl 1 IGNATUR ) PHONE W/AREA ODE .� <br /> 9 -9� <br /> FOR LOCAL A NCV USE ONLY <br /> ADMINISTRATING AGENCY <br /> y�, CITY CODE COUNTY CODE <br /> /fes[ <br /> CONTACT PERSON PHO E W/A EA CODE <br /> �© <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> t I O1 YES 1 1 02 NO <br /> HSC04-070185 PAGE 2 <br />