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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. f )'01 RUBBER LINED ( 1 02 ALKYO LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING. <br /> 1 1 07 UNLINED ( 1 08 UtfKuOWN ( 1 09 OTHER: <br /> F. ( I 01-POLYETHLENE WRAP t 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> 11 ( ) 06 TAR OR ASPHALT ( 1 09 OTHER= <br /> VI PIPING _ <br /> A. ABOVEGROUND PIPING= ( ) 01 OOUBLE-WALLEO PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04' PRESSURE t ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> B. U)IOERGROUNO PIPING: ( klol DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> LISO1 VUAL ( l 02 STOCK INVENTORY t l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GP.OU140 WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( 1 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 /> CVPXENTLY PREVIOUSLY DELETE CAS)( (IF KNOWN) CHEMICAL 400 NOT USE COMMERCIAL NAME) <br /> STORED STOR'_D <br /> 1 ) 01 ( ) 02 003 ( 1111 1 1 1111 11 <br /> O 01 ( 1 02 ( 1 03 LI I I I I I 1 I I I I I <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( 1 Ol ( ) 02 ( ) 03 I I I I I I I I I I <br /> ( ) 01 ( ) 02 ( ) 031111111111111 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> t <br /> 1 ) O1 ( ) 02 () 0311111 1 1111111 <br /> t ) 01 O 02 ( 1 03 LI I I I I I I I I I I <br /> t ) 01 ( ) 02 ( ) 03 j <br /> I ) 01 O 02 ( 1 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> IS lr. 'ITAINER LOCATED ON AN AGRICULTUP.AL FARM? ( ) 01 YES �( �02 NO <br /> THHIS FORM HAS WN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> F,,-t-.S-0 14PILIN fIGNATUPE PHONE W/AREA CODE <br /> FOP. LOCAL AGENCY SE ONLY <br /> ADMI"ISTPATING All CITY CODE COUNTY CODE <br /> �a - _ _ � Z_ —_--_-_ <br /> _ - -- <br /> CON ACT P_FS0Np1,, PHON W/AREA CODE <br /> DATE OF LAST INSPECTION ZN COMPLIANCE PERMIT APPROVAL DATE _ TRANSACTION DATE -LOCAL PERMIT IO 0 <br /> ( 1 O1 YES ( f 02 NO <br /> ,45C04-079185 PAGE 2 <br />