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%.. <br />CONTAINER CONSTRUCTION <br />STATE IO NUMBER 00000013932006 <br />01 RUBBER LINED ( 1 02 ALKYD LINING l l 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />t ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br />01 POLYETHLENE WRAP ( 7 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN f 1 05 NONE <br />( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />4. ABOVEGROUND PIPING: ( ) 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: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( ] <br />01 VISUAL (e 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS 1,1 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS (JG 07 PRESSURE TEST JWT 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 ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />l ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />f 1 03 <br />f ) 01 <br />( ) 02 <br />( ) 03 <br />( ) O1 <br />( ) 02 <br />( ) 03 <br />( f 01 <br />( ) 02 <br />( 1 03 <br />f l 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />■ 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 BEEN COMPLETED ER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />PCRSON FSLINO ( O T RE PHONE AREA CO E �/ <br />FOR LOCAL ENCY USE ONLY <br />ADMINISTRATIN AGENCY CITY CODE COUNTY CODE <br />PERSON <br />PHONE W/AREA CODE <br />(DATE OF LAST INSPECTION IIN COMPLIANCEAS( ) 02 NO (PERMIT APPROVAL DATE (TRANSACTION DATE (LOCAL PERMIT ID 2 <br />HSC04-070185 (10/18/851 <br />1%0/ <br />\o <br />PAGE 2 <br />