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STATE ID NUMBER 00000013932004 <br />CONTAINER CON5)XUGIIUN <br />( 1 01 RUBBER LINED l ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( l 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER-. <br />01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br />( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br />'I YIF iNU <br />L (CHECKRAAlP1FPRROPRIATE• BOX(ES) ( ( 0104POURESSURELED PIPE 02 ) 05 SUCTION Cf )R 06EUNKNOWNTREW 07 NONE <br />3 GRAVITY <br />NONE <br />3. UNDERGROUND PIPING ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />nu <br />'11 LEAK ucicM,.UN <br />( l 01 VISUAL Otr02 STOCK INVENTORY ( 104 VAPOR SNIFF WELLS f� 05 SENSOR INSTRUMENT <br />( ) 06 GROUND W TER MONITORING WELLS rF 07 PRESSURE TEST 09 NONE ( ) 10 OTHER! <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />-_ .,.... .... k— manIlTeen Tn rnMPtETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CASK (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( l 02 <br />( <br />) 03 <br />( ) Ol <br />( l 02 <br />( <br />) 03 <br />[ ) Ol <br />( 1 02 <br />( <br />) 03 <br />f ) 01 <br />f l 02 <br />( <br />) 03 <br />( 101 <br />( ) 02 <br />( <br />) 03 <br />l ) Ol <br />( 1 02 <br />( <br />) 03 <br />l ] 01 <br />( ) 02 <br />( <br />) 03 <br />( 1 01 <br />( ) 02 <br />( <br />) 03 <br />( ) 01 <br />( 1 02 <br />( <br />) 03 <br />( ) 01 <br />( ) 02 <br />( <br />) 03 <br />x CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />[S CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br />THIS FORM HAS <br />BEEN <br />COMPLETED UNDER THE PENALTY <br />OF PERJURY AND, <br />TO THE BEST OF <br />MY KNOWLEDGE, IS TRUE AND CORRECT. <br />PERSON FILI <br />(Si)NATVR <br />FOR LOCA GENCY USE ONLY <br />ADMINISTR G AGENCY CITY CODE COUNTY CODE <br />CONTACT PERSON (PHONE W/AREA CODE <br />(DATE OF LAST INSPECTION IIN COMPLIANCE `PERMIT APPROVAL DATE (TRANSACTION DATE (LOCAL PERMIT ID K <br />( ) 01 YES f ) 02 NO <br />HSC04-070185 (10/18/85) PAGE 2 <br />�ftm/ woo <br />