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• STATE ID NUMBER 00000037607003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED f ) 02 ALKYD LINING ( ] 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f l O1 PO:LYETHLENE WRAP ( l 02 VINYL WRAPPING ( ] 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER) <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B (CHECKRAPPR PRIATEPIPING: <br /> BOX(ES) ( ( 01 4 PRESSUREDOUBLE-WALLED(X)I 05 SUCTION CONCRETE-LINED 6UNKNOWNTRENCH 07(NONE <br /> GRAVITY <br /> VII LEAK DETECTION <br /> ENT <br /> f ( ) 06ISUAL GROUND(X) 02 STOCK WATER MONITORINGNTORYWELLS (()C)007VAPOR <br /> PRESSURESNIFF <br /> TESTWELLS 1(09 NONE05 EN501 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 (CO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> t l 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 101 ( ) 02 ( 1 03 <br /> ( ) 01 l 1 02 f 1 03 <br /> ( ) 0.1 ( 1 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON ANAGRICULTURAL FARM? ( ) O1 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 /AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> AOT�+ISTRAT� AGENCY t� 1- CITY CODE COUNTY CODE DE <br /> JCG�'C � Cz/YC �OL1�,,�z�2'�L �//1%iG✓l/ z <br /> CONT CT PERSO/N/G<� PX/2I f? AREA CODE <br /> -57 3�y/ <br /> DATE Cy LATIGNNSPECTION IN COMPLIANCE PERMIT APPROVAL DATE L Z TLR{ANS AdIOTION DATE LOCAL PERMIT ID R <br /> / ( 1 O1 YES 1 ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />