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STATE ID NUMBER 00000065161002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING 1 ) 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> 1X1 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING [ ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (XI 05 NONE <br /> 1 ) 06 TAR OR ASPHALT t ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING) ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> S. UNDERGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRE H ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST (. l 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN W1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL (X) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> f ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE (X) 10 OTHER PRESSURIZED PRODUCT <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 /> f 1 01 1 ) 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> t I Ol ( ) 02 ( ) 03 <br /> ( 1 Ol t 1 02 [ 1 03 <br /> ( ) Ol f ) 02 ( 1 03 <br /> ( ) 01 f ) 02 1 103 <br /> ( 1 01 f 102 ( ) 03 <br /> ( ) Ol l 102 ( ) 03 <br /> f ) Ol ( ) 02 ( ) 03 <br /> [ 1 01 t 1 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO <br /> THIS FORM HAS BC TED R THE PENAVr OF PERJURY AND THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON F (SI T 1 PHONE W/AREA CODE <br /> `1 / <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 Y <br /> ( ) <br /> 01 YES f 7 02 NO <br /> HSC04-070185 (05/05/86) PAGE 2 <br /> 0 <br />