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%W .s <br /> STATE ID NUMBER 00000063124001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 7 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (XI 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH A) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) of 04 PRESSURE f ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NOW' <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( 104 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS (N 07 PRESSURE T ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 ( ) 02 ( ) 03 <br /> f 101 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 7 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> [ ) 01 ( 1 02 f ) 03 <br /> [ ) Ol ( ) 02 ( 1 03 <br /> ( ) <br /> al ( 1 02 ( ) 03 <br /> ( 1 01 f ) 02 ( ) 03 <br /> ■ CHECK STATE BOARD CHEMICAL CGDE LISTING FOR POSSIBLE SYNONYMS <br /> IS 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 (S AT / Q L� PHOIE W/ EA COD!_ <br /> Kms{`'' c9x.8J1 i- VC lP <br /> FOR LOCAL AGENCY USE OILY <br /> ADMINISTRATING 4G'-NCY CITY CODE COUNTY CODE <br /> CONTACT PER ty �e ,/ P AFF/ ((�REA CODE <br /> tvf 5�21G <br /> DATE OF 'ST0'�/jl NNSPG•ECTION /IN COMPLIANCE PERMIT APPROVAL DATE /U jTRANSACTION DATE LOCAL PERMIT ID # <br /> ? G7/ 4 ( ) 01 YES ( ) 03 NO <br /> HSC04-0070183 (10/18/85) 4*7 PAGE 2 <br /> Now *mol <br />