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STATE ID NUMBER 00000035194002 <br /> CONTAINER CONSTRUCTION <br /> FF. ( <br /> ::::7t <br /> LINED ( )802 ALKYD <br /> YN LINING OTHERS EPDXY LINING C ) 04 PHENOLIC LINING t 1 05 GLASS LINING <br /> NED (X) 0 <br /> ) 01 POLYETHLENE WRAP <br /> RALT ((l)02 VOTHERWRAPPING ( Y 03 CATHODIC PROTECTION (X) 04 UNKNOWN [ ) OS NONE <br /> ( ) 06 TAR OR AS <br /> VI PIPING <br /> LB. UNDERGR:0UND <br /> ------U'ND pIpING: E ) 01 DOUBLE-WALLED PIPE C ) 02 CONCRETE--LINED TRENCH [ ) 03 GRAVITY <br /> HECK APPROPRIATE BOX(E5) ( ) 04 PRESSURE ( ) 05 SUCTION t } Ob UNKNOWNTRNCH07(NON93 GRAVITY <br /> PIPING: ( lof DOUBLE-WALLED PIPE i ) 02 CONCR06 UN NOQECKPPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN [ ) 07 NONE <br /> VII LEAK DETECTION <br /> VISUAL STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR 1DSOTHERTMTRUM T <br /> l 06 GROUNfl��' WELLS ( ) 07 PRESSURE TEST .LN+ E <br /> VIII CHEMICAL COMPOSITION E O OT RMAI eo Io COMPLETETE STORED IN UNDERGROUND CONTAINERS <br /> ON <br /> IF YOU CHECKED YES TO I4 <br /> CURRENTLY PR€VIOUSLY DELETE CAS# (IF KNCWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME ) <br /> S 0PED STORED <br /> ( } 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 f ) 03 <br /> ( } OI ( ) 02 t ) 03 <br /> ( ) <br /> 01 E ) 02 f ) 03 <br /> ( ) 01 ( l 02 ( ) 03 <br /> ( ) 01 ( 1 02 t ] 03 <br /> ( } 01 i ) 02 ( l 03 <br /> t l 01 t l 02 ( l 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 COMP ET i3��UNQER THE P N TY PERJURY AND, TO THE BEST OF MY KhOWLE!DGE, I5 TRUE AND CORRECT. <br /> PHONE W/APEA CODE <br /> PERSON FILING (SIGN R <br /> t� <br /> 'POR LOCAL AGENCY USE NLY �COWNTY <br /> nis?, CITY CODE. <br /> ADMINISTP.ATING AGENCY C �+ Y f <br /> PHONE W/A� CODE &,./- /f /9 Z S <br /> CONTACT PERSON �. !� Fj v <br /> TRANSACTION DATE LOCAL PERMIT ID # <br /> DATE OF LAST INSPECTION IN COMPLIANCE P€RMIT APPROVAL DATE <br /> T ( 1 of YES ( ) 02 No <br /> �l PAGE 2 <br /> HSC04-070185 (10/18/85) <br />