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CONTAINER CONSTRUCTION <br />STATE ID NUMBER 00000001964002 <br />:. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING [ ) 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br />( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE <br />( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING:( r) y0�1 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH f ) 03 GRAVITY <br />4 <br />(CHECK APPROPRIATE BOX(ES) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. 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 />( l 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS ( l 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <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 CASA (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />f ) 01 <br />( ) 02 <br />f ) 03 <br />( l 01 <br />f 1 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( 1 03 <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( ] 03 <br />( ) 01 <br />( ) 02 <br />( 1 03 <br />( ) 01 <br />( 1 02 <br />( ) 03 <br />( l 01 <br />f ) 02 <br />( ) 03 <br />( ) 01 <br />f ) 02 <br />( ) 03 <br />( l 01 <br />f 1 02 <br />( ) 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 COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />%EPSON FILING (SINfxTURE) n 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 />COUNTY CODE <br />(DAT -c OF LAST INSPECTION IIN COOILYESCE( ) 02 NO (PERMIT APPROVAL DATE ITRANSACTION DATE (LOCAL PERMIT ID # <br />■ HSC04-070185 (10/18/85) <br />PAGE 2 <br />