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0 <br />CONTAINER CONSTRUCTION <br />isSTATE ID NUMBER 00000004680002 <br />E. ( l 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( l 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION ( l 04 UNKNOWN ( l 05 NONE <br />(X) 06 TAR OR ASPHALT ( l 09 OTHER: <br />IVI PIPING <br />A. ABOVEGROUND PIPING: ( l 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( l 05 SUCTION ( l 06 UNKNOWN ( ) 07 NONE <br />B. UNDERGROUND PIPING: ( l 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />IVII LEAK DETECTION <br />( l 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br />I VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED YES TO IV -F YOU APE NOT REQUIREO TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />( l 01 <br />( ) 02 <br />( )_03 <br />( ) 01 <br />( ) 02 <br />( l 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />IN COMPLIANCE <br />( ) 01 YES ( ) 02 NO <br />( l 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( l 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( l 01 <br />( ) 02 <br />( ) 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 U1O ER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT_ <br />PERSON FILING <br />(SIGNATURE) <br />P <br />PHONE W/AREA CODE <br />FOR LOCAL <br />AGEN Y USE ONLY <br />ADMINISTRATING <br />AGENCY <br />CITY CODE <br />COUNTY CODE <br />CONTACT PERSON <br />PHONE W/AREA CODE <br />[;ATE OF LAST INSPECTION <br />IN COMPLIANCE <br />( ) 01 YES ( ) 02 NO <br />A�M:TPROVAL <br />DATE <br />TRANSACTION DATE <br />LOCAL PERMIT ID # <br />04-070185 (10/18/85) <br />PAGE 2 <br />