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STATE ID NUMBER 00000030803003 <br /> CONTAINER CONSTRUCTION <br /> 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING t ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> t ) 07 UNLINED (X) 08 UNKNOWN ( 1 09 OTHER* <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION E l 04 UNKNOWN (X) 05 NONE <br /> 4 ) 06 TAR OR ASPHALT C ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 OCUBLE-WALLED PIPE l ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 FRE55URE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) C ) 04 PRESSURE ( } 05 SUCTION ( ) 06 UNKNOWN [ ) 07 NONE <br /> VII LEAK DETECTION <br /> t ) 01 VISUAL (X) 02 STOCK INVENTORY [ ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( l 06 GROUND WATER MONITORING WELLS C ) 07 PRESSURE TEST ( 1 09 NONE ( ) 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IP YCU CH°CYED YES TO IV-F YOU ARE NOT PEG'UT--RED TO COMPLETE THIS SECTION <br /> CUPFENTLY PREVIOUSLY DELETE CAS# (IF YNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STCREO <br /> f ) 01 ( ) 02 i 1 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( l 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> 1 <br /> 01 ( ) 02 ( ) 03 <br /> } <br /> 01 ( l 02 ( ) 03 <br /> C 1 01 ( ) 02 t 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> C ) 01 t ) 02 f ) 03 <br /> 4 l 01 C ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CO(JTAINER LOCATED ON AN AGRICULTURAL FARM? [ ) O1 YES (X) 02 NO <br /> THIS FORM HAS EEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON ILIN S A PHONE Wi.4REA CODE <br /> FOR LOCAL AGENCY USE NLY <br /> ADMINI TIN GENCY / CITY CODE COUNTY CODE <br /> CONTACT PERSON�r P E W AREA CODE <br /> #W <br /> DATE OF LAST INSPECTICN IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL FERYIT ID # <br /> C ) 01 YES I ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />