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0 <br />CONTAINER CONSTRUCTION <br />STATE ID NUMBER 00000030202002 <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING t ) 05 GLASS LINING <br />( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER <br />F. ( ) 01 POLYETHLENE WRAP t ) 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN t ) 05 NONE <br />(X) 06 TAR OR ASPHALT t D 09 OTHER <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) t ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. UNDERGROUND PIPING: ( D 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) { ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />I LEAK DETECTION <br />(f) 01 VISUAL ( 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND ATER MONITORING WELLS ( ) 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 <br />STORED <br />PREVIOUSLY <br />STOPED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( l 01 <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( ) 03 <br />[ J 01 <br />( ) 02 <br />( ) 03 <br />f 3 01 <br />( D 02 <br />( ) 03 <br />01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( D 01 <br />( ) 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />( ) 03 <br />CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( D 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 FI AN (SSG TUR ) PHONE W/AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY <br />z <br />CIT CODE <br />GOUNTY CODE <br />! <br />CONTACT PERSON <br />PHOyE W/ CODE <br />I r\ <br />ISO <br />DATE OF LAST INSPECTION <br />IN COMPLIANCE <br />PERMIT APPROVAL DATE <br />TRANSACTION DATE <br />LOCAL PERMIT ID # <br />( ) 01 YES ( ) 02 NO <br />HSC04-070185 (10/18/85) <br />i` <br />• <br />• <br />PAGE 2 <br />