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STATE ID NUMBER 00000001669002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING C ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING C ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. t ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN i ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 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 (V 05 SUCTION C ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL [ ) 02 STOCK INVENTORY C l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( 1 09 NONE C ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED 'ES 70 It-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUFPENTLY rPEVIOUSLY DELETE CASH (IF KNOWN) CHEMICAL (DO NOT USE CC"=-PCIAL NAME) <br /> STCFED STORED <br /> ( ) 01 [ 1 02 ( 1 03 <br /> i ) 01 ( ) 02 ( 1 03 <br /> ( r 01 ( ) 02 ( 1 03 <br /> ( l 01 i ) 02 i 1 03 <br /> C ) 01 t ) 02 ( 1 03 <br /> C ) 01 [ 1 02 ( 1 03 <br /> C 1 01 ( 1 02 i 1 03 <br /> ( ) 01 C ) 02 ( 1 03 <br /> ( ) <br /> 01 C ) 02 ( ) 03 <br /> C 1 01 C ) 02 f ) 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 COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING ( ONATURE) o­)_- PHONE W/AREA CODE <br /> c k J-) r <br /> FOR LOCAL AGENCY USE ONLY { <br /> ADMINISTRATING AGENCY <br /> I �� �s l CITY CODE fOUNTY CODE <br /> �1J7/v CJ v A �v6,4, f-�r <br /> CONTACT PEPSON PHONE W/AREA CC DE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( 1 01 YES f ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />