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STATE ID NUMBER 00000053238001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED <br /> (X; 0802 ALKYD UNKNOWN LINING03 <br /> OTHER' <br /> EPDXY LINING ( l 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> ( ) 07 UNLINED <br /> F. ( ) O1 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> E(CHECK <br /> VEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED UNKNOWN <br /> TRENCH ( ) 03 GRAVITY <br /> APPROPRIATE BOXES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( l 07 NONE <br /> ERGROUND PIPING ( ) 0104 PRESSURELED PIPE 02 05 SUCTION CO(X) 06EUNKNOWNTRENCH07(NONE3GRAVITY <br /> ECK APPROPRIATE BOXES) <br /> VII LEAK DETECTION <br /> ( ( TRUMENT <br /> ) VSUAL06IGROUNDtWA) 02 STOCK INVETOYTER MONITORINGNWELLS (()1007VPRESSURE APOR FTEST <br /> LL(X)(09 NONE05 ENSOR 1N0 OTHER: <br /> VIII CHEMICAL COMPOSITJIO a OF OT RMAI ED To cS S TEORH D SECUN DERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( l 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> ( l <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( l 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 /> PHONE W/AREA CODE <br /> PERSON FILING (SIGNATURE) <br /> FOR LOCAL AGENCY USE ONLY COUNTY CODE <br /> CITY CODE <br /> ADMINISTRATING AGENCY <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> LOCAL PERMIT ID # <br /> ( ) O1 YES ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />