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STATE ID NUMBER 00000020115002 <br /> jC"'Okl'AfINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING f ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> C ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f 1 01 POLYETHLE14E WRAP t ) 02 VINYL WRAPPING i ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT E ) 09 OTHER' <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> 5. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) t ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( )�) GV6 <br /> SUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS C ) 05 SENSOR INSTRUMENT <br /> ( GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YCU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEiMICAL (00 NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> ( ) 01 ( ) 02 i ) 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> ( 1 01 f ) 02 ( ) 03 <br /> ( ) 01 [ ) 02 ( 1 03 <br /> [ 1 01 t l 02 ( ) 03 <br /> t 1 01 C ) 02 ( l 03 <br /> f ) 01 [ ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( } 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> FISCONTAINER LOCATED ON AN AGRICULTURAL FARM? t ) 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 CCRRECT. <br /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> AOrINIST ATING AGENCY CITY CODE COUNTY CO3E <br /> CONTACT PERSON PHONE W/AREA Ct)DE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TsCAIVSACTION BATE LOCAL PEP.MIT ID 3t <br /> ( ) 01 YES ( ) f?2 Na <br /> HSC04-070185 (10/18/85) PAGE 2 <br />