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• • STATE ID NUMBER CONTAINER CONSTRUCTION a E. f 1 01 RUBBER LINED —(—3-82 ALKYD LINING 1 1 03 EPDXY LINING 1 ) 04 PHENOLIC LINING ( 1 05 GLASS LINING ( 1 07 UNLINED OV 48 UNKNOWN 1 1 09 OTHER'- F. THER(F. ( ) 01 POLYETHLENE WRAP 1 1 02 VINYL WRAPPING l 1 03 CATHODIC PROTECTION 6-0 .04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT f ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: 1 ) 01 DOUBLE—WALLED PIPE 1 1 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE N' ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( 1 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE 04 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION ( 1 O1 VISUAL I�G 02 STOCK INVENTORY 1 l 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT ( 1 06 GP,OU AYER MONITORING WELLS l 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV•F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL 100 NOT USE COMMERCIAL NAME ) STORED STORED DI O 02 ( 1 03 ( ) 01 () 02 ( 1031111111111111 f ) 01 ( ) 02 ( 1031111111111111 l ) 01 ( ) 02 f 1 03 ( 1 01 ( i 02 f l 03 l ) 01 f ) 02 f 1 03 1101 1 , 02 f ) 03111 I I I I I I I I I I ( ) 01 ( , 02 ( , 03 1 ) 01 f ) 02 ( 1 03 ( ) 01 f ) 02 ( 1 03 IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES 1x1 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSO ILING ONATUPE7 PNONE OWAREA CODE ��^ FOP. LOCAL AGENCY USE ONLY -/7/6J OV NOMI TP4TI ND AGlNCY AK57 CITY CODE COUNTY CODE CONTACT%ERSON l �� vl PHONE W/AREA CODE �j J /�� O DATE Oj LASTT SSPECTION IN COM /PPLLIIA`NC! PIRMIT APPROVAL DATE TT RRRANNSACTION DATE J LOCAL PERMIT ID R �� (�7 7 ( 7 Ol 1'ES ( 7 02 NO HSC04-070185 PAGE 2