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STATE IO NUMBER 00000014594007 <br /> CONTAINER CONSTRUCTION <br /> E. [ ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( l 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( l 09 OTHER: <br /> 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING t 1 04 UNKNOWN ( d 05 NONE <br /> 06 TAP. OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING= ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <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 SOX(ES) 04 PRESSURE ( ) 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> i ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( f 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 CH=CKSO YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL tDO NOT USE CCMMEPCIAL N.«ME ) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( l 03 <br /> ( ) ^i t J 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> i ) 01 t ) 02 ( ) 03 <br /> t 7 01 ( l 02 4 ) 03 <br /> ( ) <br /> al ( l 02 ( l 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> 02 ( ) 03 L <br /> ( J 01 ( ) 02 ( l 03 1_-I__I I <br /> CHECK STATE BOARD CHEMICAL CODE LISTIt,'G FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FAP.M? t ) 01 YES (XI 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 ( IGNAT E) 1 Z�4 - <br /> PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRgIING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> /A,,rre 2-4 '?-F �-yv// <br /> DATE OF LAST I�P' TION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> ( ) 01 YES 4 ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> 0 <br />