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STATE IA NUMBER <br /> CONTAINER - CONSTRUCTION , <br /> E. 1`Vbl RU56ER LINED ( 1 02 ALKYD LINING 1 4 05 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 CLASS LINING„ <br /> { 1 07 UNLINED (4 01! UNKNow t 1 09 OTHERI ` <br /> 01 POLYETHLENE WRAP t 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (✓f 04 UtlKNOWN ( i 05 NONE <br /> 1 1 06 TAR OR ASPHALT t 1 09 OTHER: <br /> VI PIPING ` <br /> A. ABOVEGROU10 PIPING= 1 1 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES1 l ! 04' PRESSURE ( 1 05 SUCTION ( 1 06 LtOMOMN ( 1 07 NONE <br /> d. LUt11ERGROU140 PIPINGI ( )X DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH 1 ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXQ5 1 (✓i 04 PRESSURE ( ! 05 SUCTION t 1 06 UtWJVWi ( 1 07 NONE <br /> VII LEAK DETECTION <br /> 1 1 01 VISUAL ( 1 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> 1 1 06 GROU10 WATER MONITORING HELLS (4 07 PRESSURE TEST 1 1 09 NONE ( 1 10 OTHER= <br /> VIlI CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REGUZRCD TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASP (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STONED STORED <br /> ( 1 01 ( 1 02 1 1 03 E 1 <br /> ( 1 01 t 1 02 1 1 03 <br /> 1 1 01 1 ) 02 i 1 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> t101 ( ) 02 ( 1 031111111111111 <br /> 1 ! 01 ( 1 02 ( 1 03 <br /> 1 1 01 11 02 ( 1 03 <br /> t 1 01 1 1 02 ( 1 03 <br /> ( 1 01 1 1 02 1 1 03 <br /> 1 1 O1 1 1 02 [ 1 03 <br /> LXC�'_ITAIUER LOCATED ON AN AGRICULTURAL FARMT t ) 01 YES t-") 02 NO <br /> THIS 'FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANO. TO THE BEST Of MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PLCS014 FILING 1SIGNATUF PHONE Ad/AREA CODE <br /> ,z_ 1r3oo1C r[c�,ae,q 2 0 9 - 5/& I- -7 F4'J <br /> 10, <br /> FOR LOCAL AGENCY USE ONLY <br /> sDY.INjsTPATING A;ENCY CITY CODE COUNTY CODE <br /> CONTACT o*cSCN PffONE Y/AQf* CODE <br /> OATC Of LAST INSEECTION IN COMPLIANCE—_–Y-- PERMIT APPROVAL DATE Ta+ANX"lrXON DATE LOCAL PERMIT IO M <br /> R--�-01 uVES` 1 -1 02-NO <br /> .�5L04-0?7]85 I PAGE 2 <br />