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STATE ID NUMBER 00000040183003 <br /> CONTAINER CONSTRUCTION <br /> E. f 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 104 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( l 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 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 /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHEL+K APPROPRIATE BOX(ES) (X) 04 PRESSURE ( 1 05 SUCTION ( l 06 UNKNOWN ( l 07 NONE <br /> VII LEAK DETECTION <br /> t ) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f l 05 SENSOR INSTRUMENT <br /> f ) 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECY!D YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# CIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> ( ) 01 ( 1 02 ( ) 03 <br /> 1 1 <br /> 01 O 02 O 03 <br /> ( l <br /> 01 ( ) 02 ( 1 03 <br /> ( l <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> ( ] O1 ( 1 02 f l 03 <br /> 01 ( 1 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> ( l <br /> al ( 1 02 ( ) 03 <br /> ( 1 O1 ( 1 02 ( ) 03 <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ] 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 /> IP- ON FILING (S NATURE) PH HE W/AREA CODE <br /> . � o_o__ -�07Z79 -277 ?o <br /> tom( <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINI STP ATING GENCY n moi] CILY CODE COUNTY COD! <br /> CONTACT PERSON - PHONE W/AR A <br /> DATE OF LAST 14PECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO x <br /> ( ) 01 YES ( ) 02 NO <br /> TP <br /> (10/18/85) PAGE 2 <br />