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STATE ID NUMBER 00000006268001 <br />CONTAINER CONSTRUCTION <br />'E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING t D 04 PHENOLIC LINING ( D 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN (`) 09 OTHER:- <br />F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION t d 04 UNKNOWN (X) 05 NONE <br />( ) 06 TAR OR ASPHALT ( d 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( 9-01 DOUBLE—WALLED PIPE t D 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE`BOX(E3) t ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. UNDERGROUND PIPING: t ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE t ) 05 SUCTION t ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />l 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />D 06 GROUND WATER MONITORING WELLS '' POFSSURE TEST ( 1 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 />STCRED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />{ ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 ' <br />( ) 03 <br />01 <br />t ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( )_03 <br />t ) 01 <br />( l 02 <br />( )_03 <br />t ➢ 01 <br />( d 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />t ) 02 <br />( ) 03 <br />C F 01 <br />( ) 02 <br />( ) 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 HAS FEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />PERSON FILL _(S TUBE) PHONE %EA CODE <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY s CITY CODE COUNTY CODE <br />a <br />CONT C PERSON PHONE W/AREA CODE <br />DATE Of LAST INSPECTION IN COMPLIANCE RERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT SD # <br />01 YES ( ) 02 NO <br />HSC04-070185 (10✓18/8S) <br />A01- 5 <br />PAGE 2 <br />