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0 STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. f 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING C ) 05 GLASS LINING <br /> f ) 07 UNLINED ff-) 08 U11KNOWN t 1 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP t D 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (yo 04 UNKNOWN t ) 05 NONE <br /> C ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE C ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) OZ CONCRETE-LINED TRENCH t ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PP.ESSURE (,7CD 05 SUCTION i 1 06 UNKNOWN t ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL i ) 02 STOCK INVENTORY i ) 04 VAPOR SNIFF WELLS t 1 05 SENSOR INSTRUMENT - <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST Q0 04 NONE t l 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 GAS# (IF KNOWN) CHEMICAL (00 NOT USE COMM€RCIAL NAME ) <br /> STORED STOPED q } <br /> f l 01 ( 1 02 C l 03 -- <br /> t ) 01 ( D02 ( 201 II I I I A <br /> 1 ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 i 1 02 ( ) 03 <br /> i l 01 f ) 02 t ) 03 <br /> ( 1 01 1 1 02 C 1 03 <br /> 11Q1 ( ? 02 ( ' 031111 [ IIIIIIPI <br /> ( ) 0I ( ) 02 E D 03 <br /> f ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( 1 02 1 ) 03 <br /> IS CO!DTAIHER LOCATED ON AN AGRICULTURAL FARM? 1 ) 01 YES (+1C) 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 /> tt�LING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> -l <br /> CONTACT PEPSON R <br /> NE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL OATE TRANSACTION DATE LOCAL PERMIT ID # <br /> f M 01 YES f 1 02 NO <br /> HSC04-070185 PAGE 2 <br />