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STATE ID NUMBER 00000008153003 <br />CONTAINER CONSTRUCTION <br />01 RUBBER LINED ( ) 02 ALKYD LINING f l 03 EPDXY LINING ( 104 PHENOLIC LINING ( l 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( 1 09 OTHER: <br />( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ] 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br />( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br />VI PIPING <br />L. ABOVEGROUND PIPING: ( ) 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 />!. UNDERGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( ) <br />01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT n J <br />( ) 06 GROUND WATER MONITORING WELLS ()!6-07 PRESSURE TEST ( ) 09 NONE PC1 10 OTHER: L „ 1_ LOn L� I/o Gi'o/S <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 l 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( 1 03 <br />( I Ol <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />( ) Ol <br />( ) 02 <br />( ) 03 <br />( ) Ol <br />( ) 02 <br />( ) 03 <br />( 1 Ol <br />( ) 02 <br />( ) 03 <br />[ ) Ol <br />( 1 02 <br />( 1 03 <br />( 1 Ol <br />( 7 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />R CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />CS 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 />'ER SO FIlINO SIO TVRE) PHONE W/AREA CODE <br />acro- _ 3 v q0th <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY <br />PERSON <br />CODE COUNTY CODE <br />PHONE W/AREA CODE <br />(DATE OF LAST INSPECTION IIN COOILYES E( ) 02 NO IPCRMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br />HSC04-070185 (10/18/85) <br />PAGE 2 <br />