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i <br />CONTAINER CONSTRUCTION <br />STATE ID NUMBER 00000001964003 <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( 1 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br />( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br />VI PIPING <br />(. ABOVEGROUND PIPING ( ') Vp1 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( 1 03 GRAVITY <br />(CHECK APPROPRIATE BOXf ESI ✓a) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />S. UNDERGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOXES) (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 ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS i ) 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 CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />f ) 01 <br />( ) 02 <br />( l 03 <br />( 1 01 <br />( ) OE <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />f ) 03 <br />( 1 01 <br />( 1 02 <br />( ) 03 <br />( ) 01 <br />f 1 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( 7.03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />02 <br />( ) 03 <br />EEE( <br />02 <br />( ) 03` <br />a 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 />IERSON <br />FT L,.�N <br />(SIGNATURE/ <br />PHONE W/AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />AOr INISTRATING AGENCY <br />CONTACT PERSON <br />CITY CODE <br />PHONE W/AREA CODE <br />CODE <br />DATE OF LAST INSPECTION IIN COMPLIANCE( ) 02) 02 NO�PERMIT APPROVAL DATEITRANSACTION DATE LOCAL PERMIT ID#APPROVAL DATEITRANSACTION DATE�LOCAL PERMIT ID ## <br />0 HSC04-070185 (10/18/85) <br />PAGE 2 <br />