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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. i } 01 RUBBER LINED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> [ ) 07 UNLINED ( 1 OE UF)Y.)IONN ( ) 04 OTHER:. <br /> F. f ) 01 POLYETHLENE WRAP 1 1 02 VINYL WRAPPING [ ) 03 CATHODIC PROTECTION ( 1 04 U(aKNOWN ( ) 05 NONE <br /> 1 ) 06 TAR OR ASPHALT f ) 04 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUNO PIPING: t ) 01 DOUBLE—WALLED PIPE ( 1 02 CONCRETE—LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI { 1 04 PRESSURE I 1 05 SUCTIOt1 ( ) 06 UNKNOWN ( } 07 NONE <br /> S. U)IDERGROUI(0 PIPING: I ) 01 DOUBLE—WALLED PIPE ( 1 02 CONCRETE—LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) I 1 04 PRESSURE ( 1 05 SUCTION f 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> E01 AL ( 1 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> 1 :6�GROU!Q WATER MONITORING WELLS 1 ) OT PRESSURE TEST ( ) 09 NONE ( I 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU AVE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL 100 NOT USE COMMEPCIAL NAME ) <br /> STORED STORED <br /> 7 <br /> 1 ) 01 c102 ( ) 13lClilff.� <br /> ( 1 al ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 ! ! ! ! ! <br /> 1 ) 01 ( } 02 ( ) 03 I --- <br /> ( ) <br /> 01 ( 1 02 ( ) 03 1 <br /> { ) 01 1 ) 02 ( ) 0LL <br /> f 1 <br /> 01 { t 02 i ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> f 1 01 f ) 02 ( 1 03 <br /> ris CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES ( ) 02 NO <br /> THIS FORM 'HAS BEEN COMPLETED PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> --j— <br /> SON FILING (SIONATUPE ) nA PHONE W/AREA COCE /4 7(a7 <br /> FOR LOCAL AGENCY USE ONLY <br /> AOMI(+ISTRATIND AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON T_.O <br /> E W/AQEA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID M <br /> f 1 01 YES f ) 02 NO <br /> HSC04-0701115 <br /> PAGE 2 <br />