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STATE ID NUMBER 00000058665002 <br />CONTAINER CONSTRUCTION <br />01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING f ) 04 PHENOLIC LINING ( ) OS GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( 1 01 POLYETHLENE WRAP ( 102 VINYL WRAPPING ('-) 03 CATHODIC PROTECTION f 04 UNKNOWN ( ) 05 NONE <br />( ) 06 TAR OR ASPHALT [ 7 09 OTHER: <br />VT PTPTNG <br />L. ABOVEGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE t 1 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) f ) 04 PRESSURE (*) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />3. UNDERGROUND PIPING: ( 1 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN Or 07 NONE <br />VII LEAK DETECTION <br />01 VISUAL (X) 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS (a%%-07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br />VIII CHEMICAL,COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />T1 1v_c 1111 1.1 NOT RFOUTPED TO COMPLETE THIS SECTION <br />CCRRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( l O1 <br />I ) 02 <br />( 1 03 <br />( ) 01 <br />( 1 02 t( <br />) 03 <br />l ) 01 <br />f l 02 <br />( ) 03 <br />( 1 Ol <br />( 1 02 <br />( ) 03 <br />( ) 01 <br />1 ) 02 <br />( ) 03 <br />f 1 01 <br />f ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />f ) 01 <br />( ) 02 <br />( ) 03 <br />•( Y O1 <br />( 1 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 UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT, <br />PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br />CONTACT PERSON PHONE W/AREA CODE <br />DATE OF LAST INSPECTION IN COMP LIANCf PERMIT APPROVAL GATE TRANSACTION DATE LOCM PERMIT ID k <br />( ) O1 YES ( 1 02 NO <br />KSC04-070185 (10/18/85) <br />PAGE 2 <br />