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STATE 10 NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER LINED f 1 02 ALKYD LINING ( 1 03 EPDXY LINING 1 i 04 PHENOLIC LINING ( 1 05 GLASS LINING w� <br /> i <br /> 107 UNLINED F�T 08 UIK(IOWN ( 109 OTHER: <br /> 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING 01 03 CATHODIC PROTECTION 1 1 04 UtMNOWN ( 1 05 NONE ` <br /> ( 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLE PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY - <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE / 05 SUCTION 1 ) 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE QV 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL f)(�02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT i <br /> ( ) 0E GP.OUIID WATER M0141TORING WELLS (_%C 07 PRESSURE TEST ( 1 09 NONE ( 1 10 OTHER: <br /> VI I I CHEMICAL COMPOSITION OF MATERIALS STORED IIJ UN[1C_RGy]r UND CO`s A-76;"� <br /> . <br /> A ':�� CntCKEO YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION ` <br /> CURSENTLY PPEVIOUSLY OELETE CASu IIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STOPED STOP'D <br /> ( 1 <br /> 01 ( 1 02 [ 1 03 IT'l I I I I LL[I I i I _ <br /> _( 1 <br /> 01 ( 1 02 1 1 03 <br /> f 1 <br /> 01— ( 1 02 ( 1 03_M1-_hL�L-_HI-LI-1-1 <br /> 1 1 01 ( 1 02 <br /> 1 1 01 ( 1 02 _( 1 0 <br /> l i 01 1 1 02 t 1 0 3—I �l_J-L <br /> ( 101f , 02 ( 10�� lIII � fIReE �� <br /> l 1 OI Ti..1 02 ( 1 03_l__L J_.L_L_1 H.-._C 1 1 <br /> _( ) 01 T (-1_02 ( 1 03-L_L_l��l�L-(-L�1�J -- -- --- � -_ <br /> I i I f f � ' f 9 I <br /> 1 1 O1 ( 1 D2 (. 1 03 <br /> ENVIRUMErYTAL HEALTH <br /> IS CC'ITAIIIER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES 102 NO - -THIS FORM FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, 15 TRUE AND CORRECT. J <br /> c!c;D•a PILI'; fSIGNATUFEf <br /> - --- - ---- -- pnD -1_ goofaac _ -- -� Ls ,– <br /> FOR LOCAL AGENCY USE ONLY <br /> A,_,a�r c cL_K 4- (} elrr_ caD eour 1, CODE <br /> �COv:A r esr^r.v PHO f wPE CODEq <br /> DATE O- LAST INiGECTI©N �COLIANcr _ a,[pmlT APPPOVAI DATE TPANSACTION OATF LOCAL PCpMIT ID P <br /> s 02 NO <br /> aiC04-0"I i R5 <br /> PAGE 2 <br />