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• • STATE IO NUMBER 00000046490001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( f 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ] 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION f 1 04 UNKNOWN f ) 05 NONE <br /> f 7 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 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-W LLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) I'� 05 SUCTION ( ) 06 UNKNOWN [ ) 07 NONE <br /> VII LEAK DETECTION <br /> [ r <br /> 01 VISUAL (X) 02 STOCK INVENTORY ( i 04 VAPOR SNIFF WELLS f ! 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS [ r 07 PRESSURE TEST ( ) 09 NONE ( 1 10 OTHER: <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 /> CUPPENTLY PREVIOUSLY DELETE GAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STO-ED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( 1 01 ( ). 02 [ ) 03 <br /> ( ) Ol ( ) 02 ( 1 03 <br /> ( r 01 ( ) 02 ( ) 03 <br /> ( r 01 ( ) 02 ( ) 03 <br /> f 7 01 ( 1 02 ( ) 03 - <br /> f ! O1 ( 7 02 ( ) 03 <br /> i, 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 BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON IN3 (SIGNATURE) PHONE W DA CODE 4//-9`77 <br /> FOR LOCAL AGENCY USE ONLY 9 <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> i-Alexvv4ex)lle� 9 S <br /> DATE OF LAST INSGPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> v- f,-; I <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />