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No Ne <br /> STATE ID NUMBER 00000065254003 <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER LINED ( ) 02 ALKYD LINING 1 ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING 1 ) 05 GLASS LINING <br /> t ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F, f ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING 1 ) 03 CATHODIC PROTECTION IX) 04 UNKNOWN f 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE I ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE t ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE f ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( I O1 VISUAL f ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS I 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 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 /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( I Ol ( ) 02 ( ) 03 <br /> ( 101 ( ) 02 ( ) 03 <br /> t I O1 ( ) 02 t ) 03 <br /> ( ) <br /> al ( ) 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> 1 ) 01 ( ) 02 f ) 03 <br /> 1 ) 01 f ) 02 ( ) 03 <br /> t l 01 f 1 02 ( ) 03 <br /> t 101 l ) 02 ( ) 03 <br /> • <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 COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <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 COMPLIANCEACT <br /> ION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES 1 ) 02 NO PERMIT APPROVAL DATE TRANS <br /> HSC04-070185 (05/05/86) PAGE 2 <br />