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• STATE ID NUMBER 00000054350001 <br /> CONTAINER CONSTRUCTION <br /> FF ( <br /> 01 RUBBER LINED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( ] 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( 1 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER <br /> l 01 POLYETHLENE WRAP ("E <br /> 02 VINYL WRAPPING (. 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) OS NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER <br /> VI PIPING <br /> A (ABOVEGOUND CHECKRAPPR PRIATE•BOXIES) ( ( DOUBLE-WALLED01104 PRESSURE ( P1PE 02 05 SUCTION CONCRETE-LINED 06UNKNOWNTR`N�H 07( ) 03 3 GRAVITY <br /> NONE <br /> B (CHECKRAPPR APPROPRIATEPIPING: <br /> BOX(ES) ( ( ) 04 PRESSUREDOUBLE-WALLED <br /> (XPIPE <br /> 05 SUCTION CONCRETE-LINED <br /> UNKNOWNTRENCH <br /> 07 NONE <br /> 3 GRAVITY <br /> NONE <br /> VII LEAK DETECTION <br /> �'{ ( <br /> 01 VISUAL <br /> GROUND WATER MONITORING 04 <br /> 007 SNIFFAPOR <br /> PRESSURETESTLLS 1(09 NONE05 10 <br /> 10S <br /> TRUMENT <br /> 6OTHER: <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 PREVIOUSLY DELETE CAS# 1IF KNOWN( <br /> CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> ( 7 01 f 1 02 ( l 03 <br /> ( ) 01 ( 1 02 < ( ) 03 <br /> f 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ] 01 ( l 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 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 /> PERSON FILING (SIGNATURE( PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> CITY CODE <br /> ADMINISTRATING AGENCY <br /> COUN�CODE <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 1D # <br /> ( 1 O1 YES t ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />