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STATE ID NUMBER 00000058665001 <br />CONTAINER CONSTRUCTION <br />:. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f ) 05 GLASS LINING <br />fX) 07 UNLINED ( ) 08 UNKNOWN ( 1 09 OTHER: <br />01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING l 03 CATHODIC PROTECTION ) 04 UNKNOWN f ) 05 NONE <br />( ) 06 TAR OR ASPHALT f 1 09 OTHER: <br />VI PIPING <br />1. ABOVEGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (tl 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />). UNDERGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( ) <br />01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS f 1 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 />f ) 01 <br />f 1 02 <br />( ) 03 <br />( ) 01 <br />f ) 02 <br />( 1 03 <br />( ) 01 <br />( ) 02 <br />f ) 03 <br />f ) 01 <br />f l 02 <br />[ 1 03 <br />f ) 01 <br />f ) 02 <br />( ) 03 <br />( ) Oi <br />f ) 02 <br />( ) 03 <br />( )Ol <br />f )02 <br />( )03 <br />f ) 01 <br />( 1 02 <br />( 1 03 <br />f ) 01 <br />f ) 02 <br />( ) 03 <br />( ] 01 <br />( 1 02 <br />( 1 03 <br />• CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />ES CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br />THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />PERSON FILING (SIGNATURE) <br />�. Pum-d�IMA��� PHONE W/ArEA <br />�OE�� <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY <br />CONTACT PERSON <br />CITY CODE (COUNTY CODE <br />PHONE W/AREA CODE <br />KATE OF LAST INSPECTION JIM C001LYESCEf ) 02 NO (PERMIT APPROVAL DATE ITR ANSACTION DATE (LOCAL PERMIT ID # <br />HSC04-070185 (10/18/85) <br />%.1 I -W <br />PAGE 2 <br />