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STATE ID NUMBER 00000060135001 <br />CONTAINER CONSTRUCTION <br />E. ( l 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING t ) 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br />( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( <br />) 01 DOUBLE -WALLED PIPE <br />( ) 02 <br />CONCRETE -LINED TRENCH ( <br />) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) <br />( ) 04 PRESSURE ( l 05 <br />SUCTION <br />( l 06 UNKNOWN ( 1 07 <br />NONE <br />B. UNDERGROUND PIPING: ( <br />1 01 DOUBLE -WALLED PIPE <br />( 1 02 <br />CONCRETE -LINED TRENCH ( <br />) 03 GRAVITY <br />(CHECK APPROPRIATE BOXCES) <br />( ) 04 PRESSURE (X) 05 <br />SUCTION <br />( ) 06 UNKNOWN ( ) 07 <br />NONE <br />VII LEAK DETECTION <br />( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( l 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( l 09 NONE ( l 10 OTHER: <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED IES TO IV -F YOU APE NOT RE^ZUIP.ED TO COMPLETE THIS SECTION <br />CURRENTLY <br />STOPED <br />PRE':IOUSLY <br />STOPED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( l 02 <br />( ) 03 <br />( ) 01 <br />t ) 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />( 1 03 <br />( ) 01 <br />( l 02 <br />( J 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />f ) 02 <br />( ) 03 <br />( J 01 <br />f ) 02 <br />( ) 03 <br />( ) 01 <br />( 1 02 <br />( ) 03 <br />* CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />IIS 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 (SIGNATURE) ,, PHONE W/AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />A.DMINISTP.ATING A ENCY CITY ODE COUNTY CODE <br />CONTACT ORSON, PHONE W/AREA CODE <br />DATE OF LAST INSPECTION �IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br />( ) 01 YES ( l 02 NO <br />5C04-070185 (10/18/85) PAGE 2 <br />