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v, <br />CONTAINER CONSTRUCTION <br />STATE ID NUMBER 00000013932002 <br />01 RUBBER LINED f 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING f ) 05 GLASS LINING <br />( ) 07 UNLINED (X) 06 UNKNOWN ( ) 09 OTHER: <br />( ) <br />01 POLYETHLENE WRAP ( 7 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br />( ) 06 TAR OR ASPHALT f l 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING= ( 1 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (. ) 06 UNKNOWN ( ) 07 NONE <br />3. UNDERGROUND PIPING: ( 1 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />.(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />f ) <br />01 VISUAL ( ) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS f 105 SENSOR INSTRUMENT <br />i ( ) 06 GROUND WATER MONITORING WELLS l 1 07 PRESSURE TEST (X) 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 <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />f I 01 <br />( ) 02 <br />( ) 03 <br />f ) 01 <br />( ) 02 <br />( ) 03 <br />f ) al <br />f 1 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />l l Ol <br />l 1 02 <br />( ) 03 <br />( ) Ol <br />( ) 02 <br />( l 03 <br />( I O1 <br />f 1 02 <br />( 1 03 <br />f ) 01 <br />f 1 02 <br />( l 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( 101 <br />f 1 02 <br />( ) 03 <br />• CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />ES CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br />THIS FORM HAS BEENCW4KLETED UNDER TH�EEPPE'NAALTTY/OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />PERSON FILINO (S RHON! <br />FOR LOCAL NCY USE ONLY <br />ADMINISTRATI AGENCY CITY COO! COUNTY COD! <br />PERSON <br />PHONE W/AREA CODE <br />(DATE OF LAST INSPECTION IIN COOILYESCE( ) 02 NO (PERMIT APPROVAL DATE (TRANSACTION DATE (LOCAL PERMIT ID # <br />HSC04-070185 (10/18/85) <br />`/ \so <br />PAGE 2 <br />