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STATE ID NUMBER 00000010994001 <br />r n.)rAT.)Co PMMCTDIIPTT(l Al <br />01 RUBBER LINED ( 1 02 ALKYD LINING ( 103 EPDXY LINING ( ) 04 PHENOLIC LINING f ] 05 GLASS LINING <br />( 1 07 UNLINED (X) 08 UNKNOWN ( 1 09 OTHER: <br />F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X1 04 UNKNOWN ( 1 05 NONE <br />( 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br />IT DTDTWr <br />1. ABOVEGROUND PIPING: ( 1 01 DOUBLE -WALLED PIPE ( 1 02 CONCRETE -LINED TRENCH ( 1 03 GRAVITY <br />(CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( l 06 UNKNOWN ( 1 07 NONE <br />3. UNDERGROUND PIPING: ( 1 01 DOUBLE -WALLED PIPE ( 1 02 CONCRETE -LINED TRENCH ( l 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br />VTT LEAK DETECTION <br />( 1 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br />( l 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( 1 09 NONE ( 1 10 OTHER: <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />TE YOU CHECKED YES TO IV -F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( 1 01 <br />( ) 02 <br />( 1 03 <br />( 101 <br />( 1 02 <br />( ) 03 <br />( 1 01 <br />( 1 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( 1 03 <br />( 1 01 <br />( ) 02 <br />( 1 03 <br />( 1 01 <br />( 1 02 <br />( ) 03 <br />f 1 01 <br />( 1 02 <br />( 1 03 <br />( 1 O1 <br />( 1 02 <br />( ) 03 <br />I 1 01 <br />( ) 02 <br />( 1 03 <br />( l 01 <br />( 1 02 <br />( 1 03 <br />* CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />:S 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 />JEPSON FILING (SIGNATUR ` PNONE W/A EA CODE <br />4-7 <br />FOR LOCAL AGENCY USE ONLY <br />AOM[IIyN�,I,STRATING <br />AGENCY <br />fCITY <br />C <br />COUNTY CODE <br />-M� <br />_j <br />(S+rl <br />CONTACT PERSON <br />PHONE W/AREA C OE <br />( <br />ScAryllA <br />DATE OF LAST INSPECTION <br />INCOMPLIANCE <br />PERMIT <br />APPROVAL DATE <br />TRANSACTION <br />GATE <br />LOCAL PERMIT IO # <br />( 1 01 YES ( <br />) 02 NO <br />HSC04-070185 (10/18/85) <br />PAGE 2 <br />