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STATE ID NUMBER 00000066655001 <br />CONTAINER CONSTRUCTION <br />t ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 OS GLASS LINING <br />I ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER= <br />( 1 <br />01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 11N(HOWI ( ) 05 NONE <br />( ) 06 TAR OR ASPHALT ( 1 09 OTHER= <br />VI PIPING <br />1. ABOVEGROUND PIPING: ( l 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 LWNOWN ( ) 07 NONE <br />3. UNDERGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( 1 <br />01 VISUAL (X) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS < 1 07 PRESSURE TEST ( 1 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 />STORED <br />DELETE CAS# IIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />[ ) Ol <br />( ) 02 <br />( ) 03 <br />1 ) 01 <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />( ) Ol <br />( ) 02 <br />( ) 03 <br />f )O1 <br />( )02 <br />( )03 <br />[ ) OIL <br />( ) 02 <br />( ) 03 <br />( )01 <br />( )02 <br />( )03 <br />( ) O1 <br />( ) 02 <br />( 1 03 <br />[ ) O1 <br />( ) 02 <br />f 1 03 <br />• CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />iS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br />THIS FORM HAS BEEN COMP TED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />PERSa FILING LV% RE) i PHONE W/AREA CODE <br />FOR( OCAL AGENCY USE ONLY <br />ADMINISTRATIN9,.&GENCY f <br />CODE ICOUNTY CODE <br />PtWNE W/AREA CODE <br />(DATE OF LAST INSPECTION IIN COMPLIANCE( ) 02 NO (PERMIT APPROVAL DATE (TRANSACTION DATE (LOCAL PERMIT ID # <br />YES <br />HSC04-070185 (08/29/86) PAGE 2 <br />