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STATE ID NUMBER 00000065139003 <br /> CONTAINER CONSTRUCTION <br /> E. 1 ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( l 04 PHENOLIC LINING 1 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN t ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP [ ) 02 VINYL WRAPPING f 103 CATHODIC PROTECTION t 9 04 UNKNOWN ( 1 05 NONE <br /> 1X1 06 TAR OR ASPHALT 1 ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE [ ) 02 CONCRETE-LINED TRENCH bL) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 1 ) 04 PRESSURE t ) 05 SUCTION t ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE [ I OS SUCTION t ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( l 01 VISUAL (X) 02 STOCK INVENTORY ( 104 VAPOR SNIFF WELLS ( 105 SENSOR INSTRUMENT <br /> 1 ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-P YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 1 ) 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> t ) 01 l ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 t ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> 1 101 ( ) 02 l 103 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> 1 ) Ol ( ) 02 ( ) 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 FORM HAS BEEN C D UNDER THE PENALTY OF PERJURY , TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIPHONE W/ARCA CODE r� <br /> W DE J <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/ARCA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> l ) <br /> 01 YES 1 1 02 NO <br /> HSC04-070185 105/05/86) PAGE 2 <br /> 1/ \00, <br />