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0 STATE ID NUVBER 00000021915001 <br /> CONTAINER CONSTRUCTION <br /> E. ( l 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING f ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> i ) 07 UNLINED (X) D8 UNKNOWN ( ) 09 OTHER. <br /> F. ( l 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( a 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> f ) 06 TAR OR ASPHALT ( ) 09 OTHER <br /> VI PIPING <br /> A. ABOVEGROUND PIPING t ) 01 DOUBLE—WALLED PIPE ( 1 02 CONCRETE—LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) t ) 04 PRESSURE t ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING ( l 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) i ) 04 PRESSURE (X) 05 SUCTION l ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( l 01 VISUAL (Xl 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( i 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <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 /> CUF.RENTLY PREVIOUSLY DELETE GAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( l 02 ( ) 03 I I I I ) I I I <br /> ( 3 <br /> 01 i l 02 ( ) 03 <br /> ( ) O1 t l 02 f ) 03 <br /> ( 1 01 ( l 02 ( ) 03 <br /> [ ) <br /> 01 1 1 02 ( ) 03 <br /> ( ) 01 ( a 02 ( ) 03 <br /> 1 Ll <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( l 02 ( 1 13.1-1 I I I I I I 1 <br /> ( ) 01 ( l 02 t ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 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 f SIGNATURE) a_ y"'L'^ PHONE /Wql EA CODE�6,3 ,� O14' <br /> vli�rU L <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITCQOE COUNTY CODE <br /> LO� !//Ili <br /> CONTACT PERSON PHONE W/AR CODE <br /> � �_-r\ U0 b3 -D <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> t 1 <br /> 01 YES 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> 0 <br />