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ti' ..0, <br /> STATE ID NUMBER 00000019658009 <br /> CONTAINER CONSTRUCTION <br /> 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LININ ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X1 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ] 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION l ) 04 UNKNOWN ( l 05 NONE <br /> (X) 06 TAR OR ASP14ALT ( 7 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE ( ) 05 SUCTION m 06 UNKNOWN ( ) 07 NNE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE HQT 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ;( l O1 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> 1 106 GROUND <br /> WATER MONITORING WELLS ( 1 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 PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> (X) 01 ( 102 ( ) 03 MOTOR OIL <br /> ( ) O1 f 1 02 ( ) 03 <br /> ( 101 ( ) 02 ( 1 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> f 1 <br /> al ( 102 ( ) 03 <br /> ( 1 01 f ) 02 f l 03 <br /> ( ) O1 ( ) 02 ( l 03 <br /> 1 101 ( 1 02 ( 1 03 <br /> ( ) 01 ( ) 02 f 1 03 <br /> ( 1 61 f ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (XI 02 NO <br /> THIS FOR S BEEN COMPLETED HE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AN CORRECT. <br /> RS ILI O (SIGNATURE) - P E W/ EA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATI NO AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON P ONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PER <br /> APPROVAL DATE TRANSACTION DATE _FCAL ID # <br /> ( ) O1 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> Novol �� <br />