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�y STATE IO NUMBER 00000057927003 CONTAINER CONSTRUCTION E. f 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X1 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT l ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (Yl 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION f0(-1 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION .HH 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS f l 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST f 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 CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED ( ) 01 ( ) 02 1 ) 03 ( t 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( l O1 ( ) 02 ( ) 03 1 1 O1 ( ) 02 ( ) 03 ( ) 01 i ) 02 ( ) 03 ( ) 01 f ) 02 ( ) 03 ( ) 01 ( ) 02 1 1 03 ( l 01 ( ) 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO THIS FORM H BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PE FIL (S NATUPE) PH HE W/AREA CODE FOR AGENCY USE ONLY AOM) ISTRATIN AOENCY CITY CODE COUNTY CODE /5 CONTACT ERSON PH9ME W/AREA CODE (29991) �1012_91>1�116 GATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ZD P ( ) 01 YES ( ) 02,-7 KSC04-070185 (10/18/85) PAGE 2