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• STATE ID NUMBER 00000066587002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED f l 02 ALKYD LINING ( 1 03 EPDXY LINING f ) 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP l ) 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT t ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGRO <br /> PROPRIATE•BOX BOX(ES) ( ( 0104 PRESSURELE( )1PE 02 05 SUCTION CONCRETE-LINED <br /> 06EUNKNOOWN�IN) 07 NONE <br /> 3 GRAVITY <br /> NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLS PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) t ) 04 PRESSURE 5 SUCTION ( ) 06 UNKNOWN ( ) 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 1 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 REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f 1 01 ( ) 02 ( ) 03 <br /> f 1 01 ( l 02 f ) 03 <br /> ( 1 Ol ( l 02 ( 1 03 <br /> ( ) <br /> 01 ( 7 02 ( ) 03 <br /> ( ) 01 l ) 02 l 1 03 <br /> ( ) 01 l ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) 01 f ) 02 ( 7 03 <br /> ( ) <br /> 01 f 7 02 ( ) 03 <br /> x CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 7 O1 YES (X) 02 ND <br /> THIS FORM HAS BEEN COMPLETED ER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> p,E <br /> RSON FILING (SIGNATURE PHONE AREA DE <br /> N <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY OSS CITY CODE COUNTY COC_ <br /> N �o�} Ui N Goti4(✓ f�F yr H <br /> CONTACT PERSON PHONE W� RE CDE�jV.7 _Z7 <br /> jZ60N �M bell 'VVjj //NN <br /> DATE OF LAST INSSP OJION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> /C f 7 Ol YES t ) 02 NO <br /> PAGE 2 <br /> NSC04-070185 (08/29/86) <br /> 0 <br />