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STATE ID NUMBER 00000065391011 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( i 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT { 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH l 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( } 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ! 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES1 SEI 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN t 1 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS (X) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER 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 APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CRS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> (X) 01 ( ) 02 ( l 03 111511151 0 8 POTASSIUM CYANIDE <br /> (X) 01 ( ) 02 ( ) 03 1510161614191 PoTh,* ILVER CYANIDE <br /> (X) 01 ( ) 02 ( ) 03 1716141711141-51 SODIUM CHLORIDE <br /> (X) 01 ( ) 02 ( ) 03 1114131313191 SODIUM CYANIDE <br /> (X) 01 ( ) 02 ( ) 03 111311101713121 SODIUM HYDROXIDE <br /> (X) 01 ( ) 02 ( ) 03 1.5171112151 CYANIDES. INORGANIC SALTS �� cy <br /> (X) 01 ( ) 02 ( l 03 11131817101218151 SODIUM SILICATE <br /> (X) 01 ( ) 02 ( ) 03 171611111514191 ° 1 1 * TRISODIUM PHOSPHATE (SODIUM PHOSPHATE) <br /> (X) 01 ( ) 02 ( l 03 1419171119181 * SODIUM CARBONATE (SODA ASH) <br /> (X) 01 ( ) 02 t 1 03 19111210131 �qpidrNAPTHALENE pj{ a(,M* F <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 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 /> PE FS GN TU � PHONE W/ A COD <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> t ) 01 YES ( 1 02 NO <br /> HSC04-070185 (05/05/86) PAGE 2 <br />