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0 p STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED t5J-08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (,-4-04 UNKNOWN ( 1 05 NONE <br /> ( l 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING ( ) 01 DOUBLET-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN (*\Y 07 NONE <br /> 4 <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> l (CHECK APPROPRIATE BOX(ES) ( ') 04 PRESSURE (,�05 SUCTION ( ) 06 UNKNOWN t ) 07 NONE <br /> VII LEAK DETECTION <br /> ( l <br /> 01 VISUAL Vd'"02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT`--a <br /> ( ) 06 GROUND WATER MONITORING WELLS Oq_07 PRESSURE TEST ( l 09 NONE ( ) 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 KNCWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) <br /> 01 ( ) 02 <br /> O01 t ) 02 O031111IIIIIIIII <br /> ( 1O1 ( l02 ( ) 03L_ H II I III I I I I -- - -- <br /> ( ) 01 ( ) 02 ( ) 03=1_1 1 11 1 1 1 1 1 1 1 1 _-- <br /> ( ) 01 ( ) 02 ( ) 03 1_1 I_L <br /> t ) 01 ( 102 1 03I� IIIiIIIIIII <br /> O01 ( 102 O03111Ii1i111111 <br /> ( ) <br /> 01 ( l 02 ( ) 03 I I 1 I 1 1 1 I 1 <br /> O <br /> 01 O 02 ( l 03 <br /> t 1 <br /> 01 ( ) 02 ( ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (hq'02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ryAND, TO THE <br /> THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) SAN WON <br /> LOCAL HEALTH UISTRIVt PHONE W/AREA CODE <br /> f{Ir U U �V <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 PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 PAGE 2 <br />