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STATE ID NUMBER 00000063730001 <br /> CONTAINER CONSTRUCTION <br /> E. t ) 01 RUBBER LINED 'd ') 02 ALKYD LINING ( -) 03 EPDXY LINING [ .) 04 PHENOLIC LINING t ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) .08 UNKNOWN ( ) 09 OTHER: <br /> F. (X) 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING ( ,1 03 CATHODIC PROTECTION ,-_;) 04 'UNKNOWN { ') 05,NONE <br /> ( ) 06 TAR OR ASPHALT f- 1 09 'OTHER: <br /> ' VI PIPING <br /> A. ABOVEGROUND PIPING: ( , ) 01 DOUBLE-WALLED =PIPE ( ,l 02 CONCRETE-.LINED TRENCH ( ) 03 GRAVITY _ <br /> (CHECK APPROPRIATE BOXfES). ( ) 04 PRESSURE ( )'05 SUCTION. (X)''06 UNKNOWN (' ''1 07 NONE ' <br /> B. UNDERGROUND PIPING: ( 1 01 0OU8LE-WALLED PIPE f 1, 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY <br /> (CHECK APPROPRIATE BOX('ES) ( l 04 PRESSURE (X) .05 SUCTION ( )' 06 UNKNOWN (` ) 07NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL (X) 02 STOCK INVENTORY 1 144 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS: ''G ) 07 PRESSURE TEST' [ 1 09 NONE [ 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION' D'F MATERIALS STORED IN. UNDERGROUND CON_ TAIN.ERS <br /> a IF YOU CHECKEC YES TO IV—F YOU ARE NOT:'REQUIRED TO COMPLETE THIS SECTION <br /> '! CURRENTLY PREVICUSLY DELETE CASU (IF KNOWN[, CHEMICAL .('DO NOT USE COMMERCIAL NAME) r <br /> STOPED STORED <br /> f ) 01_ ( 1 02 ( l 03 <br /> Y <br /> t ) 01 ( ) 02 <br /> i <br /> { ( ) QI ( 1 02 d 1_03 <br /> ( ) O1 ( 1 02 ( ) 03 17 <br /> t ) 01 ( ) 02 1.':1 03. f <br /> ( 1 01 [ 1 0`2 f 1,03 - <br /> F <br /> ( ) 01 4 1 02 1 1 03 <br /> ( l 01 t 1 02 ( ) 03 <br /> f <br /> 1 01 ( 1 02 ( ) 63 T <br /> ( ) 01 ( 1 02 ( J 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> • iS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 01 YES (,X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE .PENALTY OF PERJURY ANDD TO :THE BEST OF'MY-KNOWL-EOGEr IS TRUE AND CORRECT. <br /> •PEP.SON FILING (SIGNATURE) - PHONE W/.AREA CODE - <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY' - 'CITY CODECOUNTY CODE <br /> - <br /> CONTACT PERSON PHONE'W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE. PERMIT APPROVAL OATS ;TRANSACTION DATE ' LOCAL PERMIT 'ID ik <br /> r <br /> ( ) O1 YES (_ ] 02 NO - - " <br /> r: <br /> HSC04-070185 f10/18/851 PAGE 2 <br />