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AMI&AOL <br /> STATE ID NUMBER 00000013318002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING t D 03 EPDXY LINING ( D 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER= <br /> F. ( ) 01 POLYETHLENE WRAP t ) 02 VINYL WRAPPING t l 03 CATHODIC PROTECTION t ) 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT t ) 09 OTHER: <br /> VI PIPING <br /> A. 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 /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( D 05 SUCTION ( D 06 UNKNOWN t ) 07 NONE <br /> VII LEAK DETECTION <br /> at ) 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> E ) 06 GROUND WATER MONITORING WELLS ( l 07 PRESSURE TEST ( ) 09 NONE (X) 10 OTHER: LINE LEAK DETECTORS <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPP.ENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> t D 01 ( ) 02 ( ) 03 <br /> )- <br /> 01 ( ) 02 ( ) 03 <br /> t ,) 01 ( ) 02 ( ) 03 <br /> ( } 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03' <br /> t l 01 ( ) 0.2 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> ) 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM H EEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST Of MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSONLING (SIGU A PHONE W/APPA CODE <br /> 1414 <br /> FOR LOCA AGENCY USE ONLY <br /> ADMINISTRATING AGENCY / / `�- CITY CODE COUNTY CODE <br /> D 7 C 1 <br /> CONTACT PERSON PHONE W/AREA CODE <br /> / s q -- s' <br /> DATE "OF LAST INSPECTS N IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LQCAL PERMIT ID # <br /> r _ ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />