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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 I O1 9WBBER LINED ( ) 02 ALKYD LINING f 103 EPDXY LINING ( 1 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> ( t1�07 UNLINED ( 1 08 UNKNOWN ( ) 09 OTHERI <br /> F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ('-Y65 NONE <br /> ( 1 06 TAR OR ASPHALT ( 1 09 OTHER) <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( 104' PRESSURE 1 ) 05 SUCTION l 1 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING% (veil DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH 1 ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIESI ( 1 04 PRESSURE ( 1 05 SUCTION ( 106 UNKNOWN l 1 07 NONE <br /> VII LEAK DETECTION <br /> ( L 0 VISUAL 1 1 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS 1 ) 05 SENSOR INSTRUMENT 1 <br /> ( 1 06 GROU14D WATER MONITORING WELLS f ) 07 PRESSURE TEST 1 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 /> -.l <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> i <br /> ( ) Ol l 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( 1 01 f 1 02 ( 1 03 <br /> ( 1 01 l 1 02 1 1 03 I I I I I I I I I I 1 --__— <br /> ( 1 01 ( ) 02 ( 1 03 I I <br /> I al 1 1 02 1 1 03 <br /> ( Ol ( 1 02 f ) 03 <br /> I --- <br /> ( O1 f ) 02 03 <br /> 1 1 01 ( 1 02 ( ) 03 <br /> I ) 01 ( 1 02 ( ) 03 1 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES ( L. U2 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSO4 LING SIG URE) PHONE WARE ODE <br /> FO LOCAL AGENCY US 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 LOCAL PERMIT ID 4 <br /> -�( 1 O1 YES 1 1 OE NO <br /> HSC04-070185 PAGE 2 <br />