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• • <br /> STATE 10 NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED { 1 02 ALKYD LINING ( i 03 EPDXY LINING f ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED t ) 08 UNKNOWN ( 1 09 OTHER: <br /> F. I 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT I 1 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPING' ( 1 01 DOUBLE-WALLED PIP€ ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING* ( ) 01 DOUBLE-WALLED PIPE I ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (;�) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL ( ) 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MO14ITORING WELLS ( ) 07 PRESSURE TEST f ) 09 NONE 4 1 10 OTHER: -- - <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED 7O COMPLETE THIS SECTION <br /> CUPPENTLY PPEVIOUSLY DELETE CASE IIF KNOWN) CHEMTCAL IDD NOT USE COMMEPCIAL N4ME1 <br /> STOPEO STORED <br /> ( l 03 { 1 02 ( I 03 1 I I I I I I i I 1 II 1 I _ -.-- -� -------- - <br /> f ) 01 ( ) 02 ( ) 13 II <br /> ( ) 01 ( ) 02 ( ) 03 1 ��II I! 1II_--LH I II� <br /> I� I�,II <br /> I ) <br /> 01 c ) 02 ( ) 13 `L � 1_L_L�1�1_ ��- <br /> i 1 01 ( ) 02 ( 1 03 IL_M I 1 1 I I I I I ----- <br /> ( 101 ( l02 { ) 03 1llllIII1111 <br /> f 1 01 1 ) 02 f ) 03 <br /> 1 ) 01 { i 02 f l 03_L_LLL�11 ( I I <br /> ( ) 01 I ) 02 I ) 13 1 I1 1 1 1 1 1 1 .1 1 1 1 <br /> I ) 01 { ) 02_ ( 1 03I_ - <br /> IS CCATAINER LOCATED ON AN AGRICULTUP.AL 'FARM? f 1 01 YES I ) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE GEST OF MY KNOWLEDGE, 15 TRUE ANO CORRECT. <br /> P!cS0'7 FILING (SIGNATUPE ) PHON W/AREA CODE <br /> . x ) 14- 1 <br /> FOR LOCAL AGENCY USE ONLY <br /> •OMINISTPATING ASENCY T CITY CODE COUNTY CODE <br /> Lmc____ s-k r ► - <br /> COrETE T P_ SON V PHONE W/AREA CODE <br /> con 339 <br /> DATE OF LAST INSPECTION IIN CO LIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 4 <br /> !I c 1 al )ES f i az No <br /> HSC04-077185 PAGE 2 <br />