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STATE IO NUMBER 00000036542001 <br />CONTAINER CONSTRUCTION <br />01 RUBBER LINED ( 1 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f ) 05 GLASS LINING <br />( ) 07 UNLINED (X) OB UNKNOWN ( ) 09 OTHER: <br />( ) <br />01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( l 05 NONE <br />( 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br />P 21;3ClEl <br />4. ABOVEGROUND PIPING: ( 1 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES1 ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />3. UNDERGROUND PIPING: ( 1 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( 1 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) f ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />(X) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS l ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />SF YOU CHECKED YES TO IV -F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br />CURRENTLY <br />STOPED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />f ) 01 <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( 7 O1 <br />( ) 02 <br />( ) 03 <br />l 1 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( l 01 <br />( ) 02 <br />( ) 03 <br />f ) 01 <br />( ) 02 <br />( ) 03 <br />f 1 01 <br />( ) 02 <br />( ) 03 <br />■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />(S CONTAINER LOCATED ON AN AGRICULTURAL FARM? (X) 01 YES ( ) 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 />'EPSON FILING (SIGNATURE) PHONE W/AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY <br />CONTACT PERSON <br />CITY CODE <br />PHONE W/AREA CODE <br />CODE <br />DATE OF LAST INSPECTION IINCOMPLIANCE( ) 02 NO IPERMIT APPROVAL DATE (TRANSACTION DATE (LOCAL PERMIT ID # <br />HSC04-070185 (10/18/85) <br />PAGE 2 <br />