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MpSTATE ID NUMBER <br />ONTAINER CONSTRUCTION <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />(�,A 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (j") 05 NONE <br />( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br />PIPING <br />LEAK DETECTION <br />( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS (v\) 05 SENSOR INSTRUMENT <br />t ) 06 GROU14D WATER MONITORING WELLS 07 PRESSURE TEST ( ) 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 <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />( D 03 1 I I ( ( I I I } <br />A. ABOVEGP.OUND PIPING: <br />( ) 01 DOUBLE -WALLED <br />PIPE <br />( ) 02 <br />CONCRETE -LINED TRENCH ( <br />) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) <br />(<) 04PRESSURE ( <br />) 05 <br />SUCTION <br />( ) 06 UNKNOWN ( ) 07 <br />NONE <br />B. UNDERGROUND PIPING: <br />Oe) 01 DOUBLE -WALLED <br />PIPE <br />( ) 02 <br />CONCRETE -LINED TRENCH ( <br />) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) <br />t%) 04 PRESSURE ( <br />) 05 <br />SUCTION <br />( ) 06 UNKNOWN ( ) 07 <br />NONE <br />LEAK DETECTION <br />( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS (v\) 05 SENSOR INSTRUMENT <br />t ) 06 GROU14D WATER MONITORING WELLS 07 PRESSURE TEST ( ) 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 <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />( D 03 1 I I ( ( I I I } <br />( D 01 <br />( ) 02 <br />( ) 03 <br />( D 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( D 01 <br />( ) 02 <br />( ) 03 <br />O01 <br />O02 <br />(D03i111111111111 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />O 02 <br />( D 03 <br />IS COt(TAIHER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES ( ) 02 NO <br />PHIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />PE ON FILING (SIIGNATUR ) PHONE W/AREA CODE <br />/S <br />ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br />CONTACT PERSON PHONE W/AREA CODE <br />DATE OF LAST INSPECTION IN COMPLIANCE RERMIT APPROVAL DATE ]7TRANSACTION DATE LOCAL PERMIT %D # <br />( ) O1 YES ( ) 02 NO <br />HSC04-070185 <br />PAGE 2 <br />