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STATE zoNUMBER <br /> CONTAINER CONSTRUCTION ' <br /> 1 01 RUBBER LINED ( 1 02 ALKYO LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> F. POLYETHLENE WRAP 1 02 VINYL WRAPPING �q 03 CATHODIC PROTECTION ( 1 04 UNKNOWN 05 NONE <br /> 06 TAR OR ASPHALT 09 OTHER: <br /> V PIPING <br /> A. ABOVEGROUND PIPING: 1 01 DOUBLE-WALLED PIPE 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI 1 04' PRESSURE ( 1 05 SUCTION 4 ) 06 UNKNOWN ( 1 07 NONE <br /> 8. UNDERGROUND PIPING: 1 01 DOU13LE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) C)q 04 PRESSURE ( I OS SUCTION 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> 01 VISUAL Vr�J 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS 1 05 SENSOR INSTRUMENT <br /> 06 GROU1413 WATER MOtlITORING; WELLS I ) 07 PRESSURE TEST ( J 09 NONE ( 1 10 OTHER: <br /> ' <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />_ <br /> If YOU c°uc,sn vcm TO IV-f YOU ARE NOT meQUzmso TO COMPLETE THIS Secroom <br /> -CURSENTLY PREVIOUSLY DELETE CAS# (If KNOWN) CHEMICAL 400 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> I ol 02 03 <br /> 01 1 02 03 <br /> 01 02 03 <br /> 01 02 3 <br /> IS cmnxn'cw LocxTsm ON AN msnzcuLroRAL pwRnr mx YES 02 NO | <br /> ''-- - - - - ' '-- —'----'------------'------------------------- '--__-__--__-___-_-__-__'-J <br /> THIS pwwn HAS BEEN connLsrso LOADER THE pcnxLTv OF PERJURY AND, TO THE BEST OF nv KnmwLsonc. IS rnoc AND coeeccr. <br /> ~c^�: 5 1 G T v F I ponN: v/Anrw C11 <br /> FOR LOCAL AGENCY USE ONLY <br /> ^ � z`, �vor cvv <br /> ���' �� ����� �-�/�� |` �`' cnn� <br /> m <br /> n`7^c, "�" <br /> ^"`' »^ `^,` I*,"' n" /° cu�~�m°cc p:*Mxv APPROVAL DATE ^crzow o^,, LOCAL pc"nzr ,n " <br /> u ^o ' ' vz xo | IT-7-7 <br /> _ <br /> p^Gc 2 <br />