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r <br />STATE ID NUMBER 00000006224004 <br />Pi A l i°1'% A 7 Lt # n A ^L.- T A I I ATT <br />hull 11AINCK bulli -B R'U41 lUPV <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING { ) 04 PHENOLIC LINING ( D 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER* <br />F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION f ) 04 UNKNOWN (X) 05 NONE <br />( ) 06 TAR OR ASPHALT ( ) 09 OTHER= <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. U)(DERGROUND PIPIN13= ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />LEAK DETECTION <br />( ) Ol VISUAL (X) 02 STOCK INVENTORY (X) 04 VAPOR SNIFF WELLS 4 ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS 07 PRESSURE TEST t J 09 NONE ( ) 10 OTHER: <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />F YOU CHECKED -.YES TO .IV -F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE OAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />01 <br />( ) 02 <br />( ) 03 <br />D 01 <br />( ) 02 <br />( ) 03 <br />3 01 <br />( l 02 <br />( ) 03 <br />t ) 01 <br />t_) 02 <br />( ) 03 <br />{ ) 01 <br />( ) 02 <br />( ) 03 <br />i) 01 <br />( ) 02 <br />( ) 03 <br />f ) 01 <br />( ) 02 <br />( ) 03 <br />t l 01 <br />( ) 02 <br />( ) 03 <br />t ) Ol <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />* CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( J 01 YES (X) 02 NO <br />THIS FOR: HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE: IS TRUE AND CORRECT. <br />PERSON 2LIN ( IGNATURE) PHONE W/AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />ADM NISTPAT,1 AGENCY <br />V t <br />CITY CODE <br />COUNTY ODE <br />�4 <br />� <br />CONTACT PERSON jr <br />e <br />PHONE WA EA CODE'_ <br />DATE OF LAST INSPECTION <br />IN COMPLIANCE <br />PERMIT APPROVAL <br />DATE <br />TRANSACTION DATE <br />LOCAL PERMIT ID # <br />1 <br />( > 01 YES ( 1 02 NO <br />HSC04-070185 (10/18/85) <br />- k <br />PAGE 2 <br />