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• STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER LINED ( ) 02 ALKYD LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> 1 1 07 UNLINED ( ) 08 LOIK14OWN ( 1 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING ) 3 CATHODIC PROTECTION ( 1 04 UNKNOWN 1 ) 05 NONE <br /> f 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l 1 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH [ 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE l ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (J\y/�oL3 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) OAF NE <br /> VII LEAK DETECTION <br /> ( ) O1.VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS 1 ) 05 SENSOR INSTRUMENT <br /> f l 06 GROU40 WATER MONITORING WELLS 1 1 07 PRESSURE TEST ( ) 09 NONE t ) 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 100 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f l 01 I ) 02 1 1 03 I I I I I I I I I I I I I <br /> O Ol 1 1 02 f 1 03 <br /> O Ol f ) 02 ( 1 03 I I I I I I I <br /> f I Ol l ) 02 ( ) 03 <br /> 1 1 01 f ) 02 f ) 03 <br /> ( ) 01 l ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 I I I <br /> ( 1 Ol ( 1 02 ( 1 03—L <br /> 1 ) 01 ( 1 02 l 1 03 <br /> r <br /> ( 1 <br /> 01 ( 1 02 f l 03 <br /> IS CO!ITAINER LOCATED ON AN AGRICULTURAL FARM? ( ) O1 YES (7O 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 /> PEPSG LINCA SIQyy��UBE P ONE WSAREA CODE <br /> 1p I <br /> FOR LOCAL AGENCY USE ONLY <br /> AOMIN�T�GENCY 1 CITY'E COUNTY CODE <br /> CONTACT PEF.SON PHONE W/AR! CODE <br /> U(A (S r �� - 3 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO R <br /> ( ) of YES ( ) 02 NO <br /> dSC04-070185 <br /> PAGE 2 <br />