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0 <br />CONTAINER CONSTRUCTION <br />STATE ID NUMBER 00000012661002 <br />E. ( ) 01 RUBBER LINED ( ). 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 7 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHERZ <br />F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br />( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( 1 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. UNDERGROUND PIPING: ( l 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 />VII LEAK DETECTION <br />F7Gd 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br />( 7 Ob GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST C ) 09 NONE ( 1 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 />CUPPENTLY <br />STOPED <br />PREVIOUSLY <br />STORED <br />DELETE OAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) " <br />( ) 01 <br />( ) 02 <br />I ) 03 <br />( 1 Ol <br />( ) 02 <br />f ) 03 <br />( ) 01 <br />( ) 02 <br />f 1 03 <br />( l 01 <br />( 7 02 <br />( ) 03 <br />( ) 01 <br />( l 02 <br />( ) 03 <br />( ) al <br />( 1 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />t ) Ol <br />f ) 02 <br />( ) 03 <br />( ) 01 <br />l ) 02 <br />( ) 03 <br />( ) 01 <br />( 1 02 <br />( ) 03 <br />â– CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />[S CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br />ITHIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />PERSON F}LING (SIGNATURE) PHONE W/AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY I I % x CITY CODE _ ICOUNTY CODE <br />CONTACT_ PERSON LPHONE W/.AREA CODE <br />DATE OF LAST INSPECTION IIN COMPLIANCE PERMIT APPROVAL DATE (TRANSACTION DATE (LOCAL PERMIT ID # <br />( ) O1 YES ( ) 02 NO <br />1 HSC04-070185 (10/18/85) <br />PAGE 2 <br />