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0 0 STATE ID NUMBER 00000031604001 <br />CONTAINER CONSTRUCTION <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />(X) 07 UNLINED ( 1 08 UNKNOWN ( ) 09 OTHER: <br />F. E ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING i ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( l 05 NONE <br />f 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br />IVI PIPING <br />A. ABOVEGROUND PIPING: f ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN (X1,07 NONE <br />B. UNDERGROUND PIPING: f ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br />IVII LEAK DETECTION <br />( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS 0'07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED YES TO IV -F YOU A== NOT REQUIRED TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />[ ) 03 <br />( ) O1 <br />( ) 02 <br />( 1 03 <br />f ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( 1 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( 1 03 <br />( ) O1 <br />( ) 02 <br />f ) 03 <br />( l 01 <br />[ 1 02 <br />( 1 03 <br />( ) 01 <br />i 1 02 <br />( 1 03 <br />f ) 01 <br />( 1 02 <br />( ),05 <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 COMPLETEDDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />.PERSON FZLINa (SI3NATURE PHONE W/AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br />CONTACT PERSON PHONE W/AREA CODE <br />DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br />( ) 01 YES ( ) 02 NO <br />0 HSC04-070185 (10/18/85) <br />PAGE 2 <br />