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STATE ID NUMBER 00000062811003 <br />CONTAINER CONSTRUCTION <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br />( ) 06 TAR OR ASPHALT ( l 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) [ ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN (%t) 07 NONE <br />B. UNDERGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRE ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( 104 PRESSURE y 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />t ) 06 GROUND WATER MONITORING WELLS !SL07 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 />STOPED <br />PREVIOUSLY <br />STCPED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />f ) 02 <br />t ) 03 <br />f ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( I 02 <br />( l 03 <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />( l 01 <br />( l 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />t ) 01 <br />( l 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />* CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br />THIS FCRM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />PERSON F L NG (SyATUR ) PHONE W/AREA C09E <br />)R LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY CITY CODE <br />COUNTY CODE <br />` <br />�o <br />® s <br />CONTACT PERSON <br />PHONE W/ARE.A CODE <br />o <br />s'--d319 - <br />S.2/,6 <br />DATE OF LAST INSPECTION <br />INCOMPLIANCE <br />PERMIT <br />APPROVAL DATE <br />TRANSACTION DATE <br />LOCAL PERMIT ID It <br />3..25-_ 816, <br />( ) O1 YES ( <br />) 02 NO <br />HSC04-070185 (10/18/85) ;". A� <br />PAGE 2 <br />