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V Y/ STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. I 1 01 RUBBER LINED ( ) 02 ALKYO LINING 1 ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING f ) OS GLASS LINING <br /> ( 1 07 UNLINED ( ) 08 UNKNOWN 1 1 09 OTHER: <br /> F. 1 l 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING 1 ) 03 CATHODIC PROTECTION f 1 04 UNKNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT l ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t 1 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH 1 03 GRAVITY <br /> (CHECK APPROPRIATE BO)(IESI ( ) 04 PRESSURE 1 1 05 SUCTION 1 1 06 UNKNOWN ( ) 07NONE <br /> S. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH (✓1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN 1 ) 07 NONE <br /> VII LEAK DETECTION <br /> Ef 1 O1 VISUAL ( 1 02 STOCK INVENTORY 1 1 94 VAPOR SNIFF WELLS ( 1 05 SENSOR. INSTRUMEN'YT4-' ' <br /> 106 GP.DUND WATER MONITORING WELLS (yI 07 PRESSURE TEST. ( 1 09 NONE (!/4 10 OTHER; -. cr, <br /> Aw <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUNDCONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQU:REO TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAM''-) <br /> STORED STORED <br /> 1 101 "- 02 11031 I I I I I I I I I I I I <br /> _( 1 01 ( 1 02 ( 1 1 1 1 1 1 1 <br /> t 1 Ol ( ) 02 f ) 03 I <br /> ( 1 Ol ( 1 02 l i 03 u I <br /> 1 1 01 O 02 f ) 03 <br /> 1 ) 01 1 1 02 ( ) 03 <br /> 1 1 Ol_ 1 1 02 1 ) <br /> ' ' 01- ` ' 02 ` ' 03 <br /> ( ) 01 1 , 02 " 031illlllll <br /> 1 1 01 ( 1 02 ( ) 03 1 1 1 1 11 1 1 1 1 1 1 1 <br /> IS f.C!NTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES 01 02 NO <br /> (((TH��HIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY Alcor TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> Ir E R20Y FILZND (SIONATUiEV / e d PHONE W/AREA CODE <br /> ii ,y\.R.v..r,i-, Jl\l J5�_Ifli ✓A�1-- I A ° 9 (�:3 3 Y -22, 5-9 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE IOCAI P4'RMIT ID R <br /> ( 1 O1 YES ( 1 0E NO <br /> 14SC04-070185 <br /> PAGE 2 <br />