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STATE ID NUMBER 00000002918004 <br /> CONTAINER CONSTRUCTION <br /> E. f 1 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP f ] 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> f ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> [AABOVEGROUND.PIPING: f ) 01 DOUBLE-WALLED PIPE f l 02 CONCRETE-LINED TRENCH f 7 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> UNDERGROUND PIPING ( ) O1 OOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f ) 03 GRAVITY <br /> (CHECK APPRPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIREO TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED - <br /> (K Ol ( 1 02 ( ] 03 Q� <br /> ( 1 01 f ) 02 ( l 03 <br /> ( ) <br /> 01 f 1 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 ( 1 03 <br /> ( l O1 ( ) 02 ( ) 03 <br /> f ] <br /> __01 ( <br /> ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> I5 CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS F M HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> Ito <br /> ILIN^u (SIGN T R () PHONE®W//AREA CODE v '` <br /> G_Y/�.��I vV <br /> FOR LOCAL AGENCY U E ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> 5.0,E 7 ; "404e- /1eA ter/ Po <br /> CONTACT PERSON -. PHONE W/AREAC DE <br /> F7Akr-`�� 2o`� _ <br /> DATE 'LAST INSPECTION TION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) <br /> PAGE 2 <br />