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- E <br /> • STATE IO NUMBER <br /> ;C ON-TIAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING 1 1 05 GLASS LINING <br /> (XI 07 UNLINED 1 ) OB UNKNOWN ( 1 09 OTHER: <br /> F. l 1 0101 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION f 1 04 UNKNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT 1x) 09 OTHER: Uer(�lnsS WT4,p <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 1 1 04 PRESSURE l 1 05 STICTION 1 1 06 UNKNOWN fXl 07 NONE <br /> B. UIDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE l ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 00 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN 1 ) 07 NONE V,0t=2,}Bench <br /> VII LEAK DETECTION <br /> l� O1 VISUAL (�) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS 00 05 SENSOR INSTRUMENT YOLL.0 LEQT P..aA (¢hnwpr SLnPc <br /> 1 1 <br /> 06 GROUO) WATER MONITORING WELLS 1 ) 07 PRESSURE TEST l 109 NONE K) 30 OTHER= Qcp J. ,alLz+ Leak delea6rS <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 CASK IIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1O1 1102 ( 103IIIIIIIIIIIII <br /> O 01 f l 02 1 1 03 I I I ' ' I I <br /> 1 1 01 1 1 02 ( 1 03111LL1_LI <br /> O 01 1 1 02 ( 1 03 I I I I I i I 1 I I <br /> 1 1 01 ( 1 02 I 1 03 II I 1 I ILLLL_I�I_J I_II II II_ <br /> ( 1 Ol 1 1 02 1 ) 03 L I1 KIWI <br /> 1 1 Ol_ ( 1 02 ( ) 03 I I I I <br /> 1 1 01 ( 102 ( 1 031 <br /> 1 1 01 l ) 02 ( 1 03 <br /> ( 1 <br /> 01 f 1 02 ( ) 03 <br /> IS CO!7TAINER LOCATED ON AN AGRICULTURAL FARM? 1 I O1 YES 1 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> vERSON ILING ISIGNATUPEI — PMic W/MU COD[ <br /> (1108) a/'o- <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTPATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PIFSON pHOHE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE pl RMIT APPROVAL DATE TRANSACTION DAT! IOCAt PERMIT ID R <br /> ( ) O1 1'ES I 1 02 HO <br /> dSC04-070105 _._ PAGE 2 <br />