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STATE ID NUMBER <br /> ( CONTAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING l ) 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> Itt ( 07 UNLINED ( 1 OB UNKNOWN ( ) 09 OTHER! <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION I 1 04 UNKNOWN ( 1 05 NONE <br /> II ( 06 TAR DR ASPHALT ( ) 09 OTHER! <br /> VI PIPING <br /> [A. ABOVEGROUND PIPING: l ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY - <br /> (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE (A 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> 1B. UNDERGROUND PIPING: l ) 01 DOUBLE-MALLEO PIPE 1 ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> j (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION l <br /> l I O1 VISUAL yV 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT I <br /> l ) 06 BROUCI WATER MONITORING WELLS ( 107 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER! <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CMECKED YES TO IV-P YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPP!NTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> 1 1 <br /> 01 ( ) 02 ( ) 03 <br /> x ( 101 ( ) 02 11031111111111111 <br /> 03 ( 1 02 ( 1 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> . , 01 () 02 ( ) 031111111111111 _ <br /> N ( I03 ( 102 ( 031111111111111 <br /> I ) 01 ( ) 02 1 ) 03 <br /> O 03 O 02 O 03 <br /> I ) 03 O 02 1 1 03 <br /> c ) 01 ( ) 02 ( ) 03 <br /> ( 1 Ol ( 1 02 ( 103 I I I I I 11 1 1 1 1 1 <br /> � iIS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 01 YES 1x 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 /> IPlOSO LING S TUR ' PHONE W/AREA CODE <br /> =0R LOCAL AGENCY US ONLY <br /> C 1NISTRATING AGENCY CITY CODE COUNTY CODE <br /> C:NTACT PERSON PHONE W/AREA CODE <br /> GA_E OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO K <br /> ( ! 01 YES f ! OE NO <br /> -S_04-070185 PAGE 2 <br /> I <br /> .r <br />