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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING 1 ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> ( ) 07 UNLINED (J.r OS UNKNOWN 1 ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (3�r 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( l 05 SUCTION f ) 06 UNKNOWN f 107 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (off 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> f 1 O1 VISUAL Ufl 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> ( 06 GP.OUND WATER MONITORING WELLS CNd 07 PRESSURE TEST ( ) 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 /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 Ol O 0 O 03 f I I l I I I I l <br /> ( 1 <br /> 01 ( ] 0 ( 103 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> ( ) 01 l 1 02 ( 1 03 <br /> ( 1 <br /> 01 ( ) 02 ( 1 03 <br /> ( l <br /> 01 l ) 02 ( l 03 <br /> ( ) <br /> 01 ( ) 02 f ) 03 <br /> 1 1 <br /> 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> I ) 01 ( ) 02 ( ) 03 <br /> ( I <br /> IS COt(TAIHER LOCATED ON AN AGRICULTURAL FARM? f 1 01 YES L\4-02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FIIING fSIGNATUP 7 PHONE W/AREA CODE <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 PEPMIT APPROVAL DATE TRANSACTION DATLOCAL PERMIT ID # <br /> f ) <br /> 01 YES ( 1 02 NO E <br /> HSC04-070185 PAGE 2 <br />