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• <br />STATE ID NUMBER 00000062853002 <br />CONTAIIHER CONSTRUCTION <br />n • :: x <br />�f. 01 POtYETHt" WRAP 02 VINYL WRAPPING 03 CATHODIC PROTECTION 04 <br />i UNKNOWN (X) 05NONE <br />•• TARa <br />VI PIPING <br />A. A15OVEOROUND PIPING: t D 01 DDOUBLE—WALLED"PIPE' t ) 02 C R£TE—LXNED TRENCHE D 03 GRAVITY <br />CHECK APPROPRIATE BOXEES) ( ) 04 PRESSURE t ) 05 SUCTION ( ) 06 UNKNOWN f )'07 HOME <br />B. UNDERGROUND PIPING t ) 01 BLE—WALLED PIPE t ) 02 CONCRETE—LINED TRENCH E D 03 GRAVITY <br />(CHECK `APPROP IATE"PDXtES) ( ) 04 PRESSURE E 05 SUCTION t ) 06 UNKNOWN t ) 07 NONE <br />VII LEAK DETECTION <br />f ) 01 VISUAL (X) 02 STOCK INVENTORY t } 04 VAPOR SNIFF WELLS <t D 05 SENSOR INSTRUMENT <br />{; ) 06 'GROUND WATER MONITORING WELLS: 07 PRESSURE TEST f ) 09 NONE t ) lb OTHER <br />VIII CHIEhfICAL 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 (00 NOT USE COMMERCIAL NAME) <br />STOMPED, STORED <br />f ) Ol <br />t ) 02 <br />E ) 03 <br />02 <br />( ) 03 <br />t 3i 01 <br />f } 02 <br />( ) 03 <br />t T 01 <br />t J 02 <br />t J 03 <br />t l 01 <br />( ) 82 <br />f ) 03 <br />f } 01 <br />E } 02 <br />E J fl3 <br />t }' 01 <br />t } 02 <br />f ) 03' <br />t ) 01 <br />. f ) ;02 <br />f ) 03 , <br />{ ) 01 <br />t ) 02 <br />fi J 03 <br />f )01 <br />t D0,2 <br />t )fl3 <br />IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f D 01 YES (X) 02 NO <br />THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF :PERJURY AND, TO THE <br />PERSON FILI'G ('SIGNATURE) <br />FOR LOCI AGENCY USE ONLY <br />MY r" AND CORRECT. <br />sr III <br />3—j,6ql <br />ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br />itaitse <br />G35 <br />CONTACT PEPSCU PHONE W/AREA CODE <br />Er <br />DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br />s E .) 01 YES ( ) 02 NO <br />HSC04-070155 (10/18/65) <br />PAGE 2 <br />