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CONTAINER CONSTRUCTION <br />E. ( 1*'01 RUBBER LINED ( ) 02 ALKYO LINING 1 1 03 EPDXY LINING <br />07 UNLINED ( 1 08 UIIY,NOWN ( ) 09 OTHER: <br />STATE ID NUMBER <br />( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 103 CATHODIC PROTECTION ( 1 04 UNKNOWN j` 1 05 NONE <br />( 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />A. ABOVEGROU('D PIPING: l 1 01 DOUBLE -WALLED PIPE ( 1 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOXIES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br />B. UIIDERGROU140 PIPING' ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( 4 -PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />1 1 <br />101 VISUAL (�A 02 STOCK INVENTORY l 104 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br />1 I 06 GROUIID WATER MONITORING WELLS l 1 07 PRESSURE TEST ( ) 09 NONE (V 10 OTHER: r -CH <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED YES TO IV -F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br />CVP9fNTLY <br />STORED <br />PREVIOUSLY <br />STOPED <br />DELETE <br />CASK (IF KNOWN) CHEMICAL 100 NOT USE COMMERCIAL NAME) <br />O 01 <br />O 02 <br />O 03 <br />IL I I I I I I I I I <br />01 <br />(' 02 <br />( 1 13 <br />f l l l i l l l IL I I IL I <br />"01 <br />('02 <br />('031 <br />1 1 1 1 111 (I I i l <br />O 01 <br />( 1 02 <br />( 1 03 <br />I I I I I I I I I I <br />O 01 <br />O 02 <br />( 1 03 <br />11 ) I I I I I I I I <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />1, 01 <br />O 02 <br />( 1 03 <br />01 _ <br />02 <br />` -)13 <br />LLLll I I I I I I I <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 -_ <br />(-1 02_- <br />( 1 03 <br />IIIIII <br />IS CO'ITAINER LOCATED ON AN AGRICULTURAL FARM? l 1 01 YES 1 ,02 --NO l <br />THIS FORM S BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT._ <br />P! N fl�11GTUFE)PHONE W/A EA CODE - I <br />/-has rs �oln-f r►�,L <br />FOR LOCAL AGENCY USE ONLY <br />&0`:IIJ:STRATINS A;ENCY -----_-- -- ------ — CITY CODE <br />C0147, Af oeCeCN U PHON <br />DATE OF LAST INSCECTION TIN COMPLIANCE PERMIT APPROVAL DATE <br />COUNTY CODE <br />W/ARlA ).DE � R' f g - <br />TRANSACTION DATE IOCAI PERMIT ID K <br />HSC04-071185 PAGE 2 <br />