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STATE ID NUMBER 00000020115004 <br /> CONTAINER CONSTRUCTION. <br /> FE. ( E) 01 RUBBER LINED ( ) 02 ALKYD LININGl 03 EPDXY LINING [ 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 07 UNLINED [ ) 08 UN{NOWN [ l 09 OTHERPOLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION [ ) 04 UNKNOWN tX1 05 NONE <br /> 06 TAR OR ASPHALT ( ) 09 OTHER-' <br /> VI PIPING <br /> E(CHECK <br /> VEGROUND PIPING t ) 01 DOUBLE-WALLED PIPE E ) 02 CONCRETE-LINEO TRENCH t ) 03 GRAVITY <br /> APPROPRIATE BOXtES) [ l 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN t ) 07 NONE <br /> ERGROUND PIPING 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH 03 GRAVITYHECK APPROPRIATE BOXtES) (X) 04 PRESSURE [X1 05 SUCTION f ) 06 UNKNOWN t ) 07 NE <br /> VII LEAK DETECTION <br /> F1 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT <br /> 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE i ) 10 OTHER' <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECF.ED YES TO TV-F YOU APE NOT REt3UIPEO TC COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STC`r.ED <br /> ( ) 01 ( ) 02 i l 03 -�- - <br /> ( ) 01 ( ) 02 ( ) 03 <br /> i ) <br /> 01 ( ) 02 ( 1 03 - <br /> ( ) 01 ( ) 02 ( ) 03 - <br /> t 1 01 t 1 02 ( ) 03 <br /> { ) 01 ( ) 02 ( ) 03 <br /> ( l 01 { 1 02 ( ) 03 <br /> i ) 01 ( ) 02 t 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 [ ) 02 ( ) 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 /> PHDNE W/AREA CODE <br /> PERSON FILING (SIGNATURE) <br /> FOR LOCAL AGENCY USE ONLY <br /> CITY CODE COUNTY CODE <br /> ADNINISTRATIN3 AGENCY <br /> PHONE W/.AREA CODE <br /> CONTACT PERSON <br /> DATE OF LAST INSPECTION IN COMPLIANCE <br /> PERMIT APPR04'AL DATE TRANSACTION DATE LOCAL PERMIT ID <br /> ( ) 01 YES t ) 02 NO <br /> PAGE 2 <br /> HSC04-07CI85 (1C/18/85) <br />