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• • STATE ID NUMBER 00000010942001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ] 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) OB UNKNOWN ( ) 09 OTHER: <br /> F. ( ),k POLYETHLENE WRAP ( ) 02 VINYL WRAPPING l l 03 CATHODIC PROTECTION (X) 04 UNKNOWN f ] 05 NONE <br /> 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 7 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS f 1 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 /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ! 1 01 ( ) 02 ( ) 03 <br /> ! ) Ol ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> 1 1 01 ( ) 02 ( ) 03 <br /> ( 7 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ! ) 01 ( ) 02 ( 1 03 <br /> x CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X1 02 NO <br /> THIS FORM HAS BEEN COMPLETED DER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PCRSON FILING (SIGNATURE -. PHONE W/AREA CODE <br /> ze - y6 -o- —� <br /> 4 --- <br /> FOR LOCAL AGENC USE NLY <br /> ADMINISTRATING AGENCY <br /> CITY CODC COUNTY CODE <br /> CONTACT PERSON /, _L PHONE W/AREAnA COOE�. - O 7J <br /> �V� •LI _ _ <br /> DATE OF LAST INSPECTION INZOFfP'CSANCE-"`"`- �� PCRMIT APPROVAL DATE TRANSACTYOTi--DA.T.E.__ LOCAL PCRMIT ID # <br /> 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />