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STATE ID NUMBER <br />CONTAINER CONSTRUCTION <br />f. 1 1'01 RUBBER LINED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br />(�k 07 UNLINED ( 1 08 UIIY,I(OWN ( I 09 OTHER: <br />01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 103 CATHODIC PROTECTION ( ) 04 U((KNOWN Do 05 NONE <br />( 106 TAR OR ASPHALT 1 1 09 OTHER: <br />VI PIPING <br />A. ABOVEGP.OUND PIPING: ( 1 01 DOUBLE-WALLEO PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ESI ( 1 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. UNDERGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) 04. -PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br />VII LEAK DETECTION <br />PREVIOUSLY <br />STOPED <br />DELETE CASs (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />01 VISUAL <br />1 06 GP,OUIID <br />Fl <br />(l 02 STOCK INVENTORY l <br />WATER MO(IITORING WELLS <br />1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR <br />( 1 07 PRESSURE TEST ( l 09 NONE (jO <br />INSTRUMENT <br />10 OTHER: — 4 4da _5 <br />VIII C14EMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED YES TO IV -F YOU APE NOT REQU:RED TO COMPLETE THIS SECTION <br />CV09ENTLY <br />STORED <br />PREVIOUSLY <br />STOPED <br />DELETE CASs (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />( 1 01 <br />( 1 02 <br />(-1 13 <br />( 1 01 <br />( 1 02 <br />O 03 I III 1LI 1 I i 11 1 <br />l 1 01 <br />() 02 <br />( 1 03 1 1 1 1 1 1 1 1 1 1 <br />( 1 01 <br />( ) 02 <br />( ) Oil I I I I I I I I I <br />( I 01 <br />t 1 02 <br />( 1 03 <br />11 01 <br />() 02 <br />( I 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br />''01 <br />_ `'02 <br />`'03-LLI I II I I I I I II <br />t ) 01 <br />( 1 02 <br />( ) 03 <br />( ) 01 --( <br />1 02 <br />IS C04TAI14ER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES l NO <br />MMIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />,/gR 4 fIIING 1 SIGN � E) ----------------------_---- vNONC W/AR A CODE <br />-- a� _ — <br />FOR LOCAL AGENCY USE ONLY <br />(,AOI"1111STPAT Ni AGENCY ZTY COO COUNTY CO <br />De <br />o_CSC PHONE W/AREA CE �( <br />--��-QL r - -- - - - - - - - -------- � 7 6 --� -- - - <br />DATE Of LAST INSRECTION TIN COMPLIANCE PERnIi APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO a <br />( O1 )ES ( 02 1:O <br />.(SC04-0?7185 PAGE 2 <br />