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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> C. 1 1"OI RUBBER LIMED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( 104 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 07 UNLIrJED ( 1 08 UNKNOWN ( 1 09 OTHER: <br /> F. ( 1 01 POLYETHLE14E WRAP ( 1 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION ( 1 04 UIJKNOWN , 1 05 NONE <br /> 1 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE—WALLED PIPE f 1 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI I J 04' PRESSURE f J 05 SUCTION ( ) 06 UNKNOWN 1 ) 07 NONE <br /> B. LJNOERGROUND PIPING: I J 01 DOUBLE—WALLED PIPE 1 1 02 CONCRETE—LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE SUCTION ( J 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( I O1 VISUAL 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS i J 05 SENSOR INSTRUMENT <br /> ( 106 GRp WATER MO)IITORING WELLS 1 1 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 APE NOT RECU:REO TO COMPLETE THIS SECTION <br /> CUPRENTLY PPEVIOUSLY DELETE CASA TIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STOPED STOPsD <br /> ( 1 01 ( I 02 ( r 03 I_1 �1 I f <br /> { i 01 ( 1 02 ( 1 03 R I I I I I 1 i�J—(II1_ <br /> 1 1 01 ( r 02 f 1 03 H <br /> ( f <br /> 01 ( 1 02 ( 1 03 <br /> 1 <br /> 01 ( 1 02 ( 1 03 I } V I I I <br /> t i-ol ( r 02 ( s 03 <br /> 11 01 ( 1 02 1 r 03 <br /> I 1 01` ( ) 02 1 1 03 LLL-I _Il i I I I I I 1 - <br /> i <br /> 011 1 02 1 1 n3 . 1 I LH I I I I I I I _ <br /> i 02� I r 03 11 1 I l E_ LjII-_-I__J_I_ <br /> (IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? 1 1 01 YES 1 r 02 NO ' <br /> THIS FORM HA E MPLETED UNDER THE PENALTY OF PERJURY ANOP TO THE BEST OF MY KNOWLEDGE9 IS TRUE AND CORRECT. <br /> F"CSON F ' --PE ) W/AREA CO E <br /> __ fail %_f- f✓ <br /> FOR LOCAL AGENCY USE ONLY <br /> •O^'I�+;SToaTIh•D •,Er;^ r , + f� r, CIT4CODE COUNT, CODE <br /> A-0 CIO <br /> CON.ACT o`CSCN <br /> RHONE W/A A COD .✓/ <br /> DATE OF LAST INSEE ON IN COMPIIANCC [1--11EnIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID p <br /> G1 IES i 02 NO <br /> aSC04-0? 195 <br /> PAGE 2 <br />