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STATE ID NUMBER 00000001439002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP 1 1 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ] 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) Q(} 04 PRESSURE ( ] 05 SUCTION 14706 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> f ) 01 VISUAL {X) 02 STOCK INVENTORY ((k 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS (Kl 07 PRESSURE TEST (X) 09 NONE 1 ) 10 OTHER* <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 1 ) <br /> 01 ( 1 02 ( 1 03 <br /> f ) <br /> 01 ( ) 02 1 ) 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> 1 ) Ol ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( 1 03 <br /> ( ) O1 f ) 02 ( 1 03 <br /> ( 1 O1 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> f ) Ol 1 ) 02 ( ) 03 <br /> ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES fX) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY O PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IB TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) 2 PM E W/ARE COOS <br /> 2:J_t `{ . `{ 4 Z <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY TAPPPOVALTDATE <br /> COUNTY CODE <br /> CONTACT PERSON W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMITRANSACTION DATE LOCAL PERMIT ID S <br /> ( ) OI YES f ) 02 NO <br /> 8SC04-070185 110/18/85) <br /> PAGE 2 <br /> �/ yi <br />