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STATE ID NUMBER 00000059694001 <br /> CONTAINER CONSTRUCTION <br /> EF ( <br /> (701 RUBBER LI <br /> ILINED( 1 0802 ALKYID UNKNOWN LINING <br /> N09 OTHER: EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> NED <br /> (0) WRAP <br /> (()IO2 VOTHERWRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> VI PIPING <br /> FE PROPRIATE•BOX(ES1 ( ( 0104 PRESSURELED )I05 SUCTION PE 02 CON lR 06EUNKNOWNTREN lH 07(NONE3GRAVITY <br /> D PIPING:BOX(ES1 ( ( 0104OUBLE-WALLEDPIPESURE (X) 05 SUCTION 02 CONCRETE-LINED TRENCH GRAVITY <br /> CK <br /> RIATE <br /> VII LEAK DETECTION <br /> ( ( INSTRUMENT <br /> 01OVVISUAL <br /> AUN0(WX) 02 STOCK ATER MONITORINGHHEL LS TORY ((l)007VPR ESSUREAPOR FTESTLLS 1(09 NONE <br /> 05 ENSOR 10 OTHER: <br /> VI IFCHEMCoLSOMPOSITION OFMATERIALS STORED IN UNDERGROUND CONTAINERS <br /> rEREQUIRED SID <br /> CURRENTLY PRCVIOUSLY DELETE CAS# (IF KNOWN) <br /> CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 1 ) 01 ( ) 02 ( ) 03 <br /> ( 1 Ol ( ] 02 ( ) 03 <br /> ( l <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> 1 ) Ol f ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> 1 ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 f ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? (X) 01 YES f ) 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 CODC <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCCPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID R <br /> ( 7 <br /> 01 YES ( ) 02 NO <br /> • KSC04-070185 (10/18/85) PAGE 2 <br /> y <br /> z <br />