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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION - <br /> E. ( ) 01 RUBBER LINED t 3 022 ALNOWN YO LIN)ND9 OTHERS EPDXY LINING ( 1 44 PHENOLIC LINING [ 1 05 GLASS LINING <br /> ( ] 07 UNLINED <br /> -� � 04 UNKNOWN ( ) 05 NONE <br /> F, ( lCol 06TAR OR ASPHALT WRAP <br /> R ALT (f))0a9VINYL <br /> OTHERWRAPPING t ) 03 CATHODIC PROTECTION <br /> V I PIPING —_��- <br /> A. ABOVEGROUND PIPING i ) O1 DOUBLE-WALLED PIPE ( ] 02 CONCRETE-LINED TRENCH E ) 03 GRAVITY -- - -(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSUREoZ( ) 05 SUCTION ( 1 06 UNKNOWN t � ONE <br /> B, UNDERGROUND PIPING ( 1 01 DOUBLE-WALLED _PI05 SUCTION Cd;iC)R06EUHICNOWNTRN)H07(NONE3 GRAVITY- -- <br /> (CHECK APPROPRIATE BOX(ES) W 04 PRESSURE <br /> _. _ __ _ <br /> VII LEAK DETECTION ---- <br /> E) _ _1 VISUAL t 02 STOCK INVENTORY t 1 04 VAPOR SNIFF WELLS [ ) 05 SEN50R INSOTHER:4j✓LC �K �) 06 GROUND WA�tR MONITORING WELLS (� 07 PRESSURE TEST ( 1 a4 HONE ( 3 10 OTHER tl <br /> VIII CHEMICAL COMPOSITION OF RMA IRERIALS ED TO coMPeTOREDE THIS secTIvNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES T <br /> Y CHEMICAL (DC NOT USE COMMERCIAL NAME) <br /> CURRENTLY PREVIOUSLY DELETE CASU (IF KNOWN) f STORED STORED <br /> tf( )}] oafl (r !) 02 <br /> 0 02 <br /> o2 (( 11 000333 ( �- l __ ------ <br /> �- <br /> --t 1pc 1 <br /> 02 t ) 03 II �II II <br /> ( 1 01 l ) 02 ( 1 03 LI.--_LL_LL-L L <br /> t 1 01 ( ) 02 ( ] 03 - r <br /> 01 02 <br /> ( ! 01 ( 1 02 t ) 0-3 <br /> ( ! of t ) 02 <br /> C 1 01 ( ) az l ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? [ 1 O1 YES-(�'OZ NO -- - ----. .-- --�- <br /> OF PERJURY AND) TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br /> THIS FORT( HAS BEEN COMPLETED UNDER THE PENALTY --��� <br /> �. - --- -- <br /> — — / 7-t/ 0/CT?Z��'y PHONE w/AREA COD <br /> PERSOri F NG IG <br /> UP —___ ----- <br /> FOR LOCAL AGENCY USE ONLY cov*rr cooE <br /> CITY CODE <br /> aDMINISTRATING AAGEENCY �� � �` 0` - —......._.... -- <br /> y--=Tri- PHONE W/AREA CODE <br /> CONTACT PEPSON u !Z 0 — IV /6 _ <br /> PERMIT APPROVAL DATE TRANSACTION DATE LOCAL P€RMIT ID # <br /> DATE OF LAST INSPECTION I( COMPLIANCEol YES ( } 42 NO — <br /> - _ PAGE 2 <br /> HSC04-070185 <br />