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STATE ID NUMBER 00000062811004 <br />CONTAINER CONSTRUCTION <br />( l 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( l 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br />( l 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br />( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />ABOVEGROUND PIPING: ( <br />l 01 DOUBLE -WALLED PIPE <br />( ) 02 <br />CONCRETE -LINED TRENCH ( <br />) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) <br />( ) 04 PRESSURE f l 05 <br />SUCTION <br />( l 06 UNKNOWN �07 <br />NONE <br />UND€RGROUNO PIPING* ( <br />) 01 DOUBLE -WALLED PIPE <br />( ) 02 <br />CONCRETE -LINED TRENCH ( <br />) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) <br />( ) 04 PRESSURE QV. -05 <br />SUCTION <br />( ) 06 UNKNOWN ( ) 07 <br />NONE <br />VII LEAK DETECTION <br />f ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS ,L%.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 />FPEVIOUSLY <br />STOPED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( 1 02 <br />( ) 03 <br />( ) 01 <br />( l 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />* CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />:S CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br />THIS FORM S BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />PEPSONG (SIGN.ATURE) PHONE W/AREA CODE <br />1/m �, ��v a-m-_76gi <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY ^ CITY CODE COUNTII CODE <br />CONTACT PERSON PHONE W/ARE.A CODE 3 <br />i h C 1 <br />DATE OF LAST INSFECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br />3- `G ( ) 0: YES ( ) 02 NO <br />HSC04-070185 (10/18/85) M,4 4,PAGE 2 <br />