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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUSEER LINED ( ) 02 ALKYD LINING 03 EPDXY LINING ( ) 04 PHENOLIC LINING l ) 05 GLASS LINING <br /> 1 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING 93 CATHODIC PROTECTION ( ) 04 UNKNOWN K) 05 NONE <br /> ( J 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: / <br /> INED <br /> 4CHECK APPROPRIATE BOX(ES) ( 0104 PRESSURE LED )I05 SUCTION PE 02 CON;R006EUNKNOWNTR(Af 07(NONE3 GRAVITY <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( 1 03 GRAVITY <br /> _(CHECK APFROPRIATE BOX(ES) (�Q 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> E1111 <br /> ) 01 VISUAL P<) 02 STOCK INVENTORY 04 VAPOR SNIFF WELLS p,) 05 SENSOR INSTRUMENT— _/_A44— yowae 4wr TLS 2. <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER' <br /> PI ol F.J(r k j E f'M S 8OD <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKEO YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASs (IF KNOWN) <br /> STORED CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED <br /> ( ) <br /> 01 ( ) 02 ( ) 03 I I I I <br /> ( 1 <br /> 01 ( 1 02 O 03 V I I I <br /> �1_LLLI <br /> I I <br /> ( 1 01 ( ) 02 ( ) 03 1-1—t I—L1_ <br /> ( ) Ol ( ) 02 <br /> ( ) <br /> 01 ( ) 02 ( ) 03Ll I I I_ t _IL <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 [ J 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> EISCONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES ( 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 PILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINIL,RATZNG ENCY CITY CODE <br /> COUNTY CODE 2Z- <br /> U <br /> CONT T PERSON PHONE W/AREA CODE <br /> 1 �C ol!! =11COMILYZA1,NCE <br /> DATE OP LAST INSPECTIOPERMIT APPROVAL DATE( ) 02 NO IOCAI PERMIT ID • <br /> HSC04-070185 <br /> PAGE 2 <br />