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• . STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING [ ) 05 GLASS LINING <br /> _42Q, 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN t ) 05 NONE <br /> (]Q 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l ) 01 DOUBLE-WALLED PIPE l ) 02 CONCRETE-LINED TRENCH 1 ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04' PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN 07 NONE <br /> S_.` <br /> B. UNDERGROUND PIPING: -Ar 01 DOUBLE-WALLED PIPETRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE �05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL X402 STOCK INVENTORY f I.04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT - <br /> ( ) 06 GROUND-AWA R MONITORING WELLS V7 PRESSURE TEST ( ) 09 NONE ( 1 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 IDO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> [ 1 01 ( ) 02 O 03 <br /> ( 101 ( ) 02 ( ) 03 <br /> t ) 0I ( ) 02 ( ) 03 <br /> l 101 ( ) 02 ( ) 03 <br /> f ) 01 t ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( 102 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f l 01 ( ) 02 ( ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES �02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br /> PERSON (SI NAT .E' PHON <br /> FOR LOCAL AGENCY USE OJLY JJ 7(7( QO <br /> ADM-AR TIN 30ENCY _ �( N L_c) (`S,/ ` ,� CITY CODE COUNTY CODE <br /> CONTACT/PIERS �_[ `yp`�- , -7 4p� -{1-`:�H.1�\L` PHONE W/AREI� yy10 E'��' .�/�� <br /> DATE OF LAST INSR C ON IN COMPLIANCE PERMIT APPROVAL DATE TRAANNS`/A'CCTII/ON SDATE v, LOCAL PERMIT IO # <br /> ( 1 Ol YES ( 1 02 NO <br /> HSC04-070185 PAGE 9 <br />