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ti <br />• <br />. STATE ID NUMBER <br />CONTAINER CONSTRUCTION <br />1. 1 1"01 RUBBER LINED ( 1 02 ALKYO LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING t 1 OS GLASS LINING <br />(1%k 07 UNLINED ( 1 08 UNKNOWN l 1 09 OTHER: <br />P. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (y 05 NONE <br />( 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: t ) 01 OOUBLE-WALLED PIPE ( 1 02 CONCRETE -LINED TRENCH ( 1 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04' PRESSURE l 1 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br />B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLEO PIPE ( 1 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ()Q 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( ) 01 VISUAL ('�) 02 STOCK INVENTORY l 1 04 VAPOR SNIFF.WELLS ( 1 05 SENSOR INSTRUMENT <br />( ) 06 GROU140 WATER MONITORING WELLS ! ) 07 PRESSURE TEST ( 1 09 NONE ()Q 10 OTHER: 1� <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED YES TO IV -F YOU ARE NOT REQU/RED TO COMPLETE THIS SECTION <br />CUVCENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE <br />CASH (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />` )O1 <br />( )02 <br />103LL1� <br />N I I I I I I I <br />01 <br />(102 <br />11031111111111111 <br />f ,(I1 <br />()02 <br />( 1031 <br />11 1 1 1 1 1 11 1 11 <br />t101 <br />102 <br />)03 <br />IIIlilllll <br />Ool <br />( 02 <br />O03Llilill(III <br />t 1 01 <br />( ) 02 <br />( ) 03 <br />f ) 01 <br />( ) 02 <br />( ) 03 <br />1 01 _ <br />1 1 02 <br />( 1 03 <br />LI I I I I I I I I I I I <br />( 1 01 <br />( ) 02 <br />( _)03 <br />_ <br />1 01 <br />_( 1 02_ <br />(' 03 <br />1 I I I I l l l l l l l l <br />IS CO'(TAINER LOCATED ON AN AGRICULTURAL FARM? <br />TH7FF.HA <br />PI -L I <br />( ) 01 YES <br />02 NO <br />BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANDS TO THE BEST OF MY KNOWLEDGE9 IS TRUE AND CORRECT. <br />is <br />-,l TUFE I PHONE W/AREA CODE <br />FOR LOCAL RGENCY USE ONLY <br />AO`:I++ STATT N A,Er Y CITY <br />CONTA DrC N <br />DATE OF LAST INSVECTION IN COMPLIANCE PERMIT APPROVAL DATE <br />1 C1 YES ( + 02 NO <br />.4SC04-070185 <br />OE (COUNTY CODE <br />PHONE W/FREA CODE <br />o7 <br />TRANSACTION DATE LOCAL PERMIT ID 9 <br />— — J -- <br />