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CONTAINER CONSTRUCTION ../ E. ( ) 01 RUBBER LINED STATE TD NUMBER 00000004291003 (X) 07 UNLINED ( ) 02 ALKYD LINING ( ) 08 UNKNOWN ( ) 09 ( ) 03 EPDXY LINING F. ( > 01 POLYETHLENE WRAP OTHER: ( ) 04 PHENOLIC LINING ( ) 02 VINYL WRAPPING ) 05 BLABS LINING ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: ( ) 03 CATHODIC PROTECTION VI ( ) 04 UNKNOWN (X) 05 NONE PIPING A. ABOVEGROUND PIPING: (CHECK APPROPRIATE BOXES) ( ) 01 DOUBLE-WALLED PIPE ( 02) 04 PRESSURE ( ) 05 SUCTION CONCRETE-LINED TRENCH 8• 11NDERGROUND PIPING: ( ) Ob UNKNOWN ( ) 07NONEGRAVITY (CHECK APPROPRIATE SOX(ES) f ) O1 UBLE-WALLED PIPE ( ) 04 DOPRESSURE (X) 05 ) 02 CONCRETE-LINED TRENCH SUCTION ( ) 06 UNKNOWN ( ) 07fNONE3 GRAVITY VII LEAK DETECTION yI 1 01 VISUAL (X) 02 STOCK INVENTORif GROUND WATER Y ) 04 VAPOR SNIFF WELLS MONITOR ( 7 ( ) MONITORING WELLS �) 07 PRESSURE rear 05 SENSOR INSTRUMENT ( ) 09 NONE ( 1 10 07HER: 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 CAS# (IF KNOWN) STORED STORED CHEMICAL (DO NOT USE COMMERCIAL NAME) ( ) 01 ( ) 02 f ) 03 f ) Ol ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( 1 02 ( l 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ] 02 f ) 03 f ) 01 f ) 02 O 03 ( ) 01 ( ) 02 ( ) 03 ( 1 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 HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FIL NG (SIGNATURE) PHONE W/AREA CODC Caoq a - 51p� FOR LOCAL AGENCY USE ONLY AD. NIST RAT AGENCY ,a�r�/I_� / CITY CODE COUNTY CODE PH CONTiS;O'N` _ /�//- ,- NE W/AREA CODE-S 1045/ DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DAT! LOCAL PCRMIT ID # 3 ��6 01 YFS ( ) 02 NO PAGE 2 KSC04-070185 (10/18/85)