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STATE 10 NUMBER 00000004310001 <br /> gNotg <br /> ONSTRUCTION04 <br /> NG <br /> E. ED l ) 02 ALKYD LINING ( ) 03 EPDX7 LINING ( PROTECTION L(X LOpUNKNOWN <br /> 05 6LA05S NONE l ) OB UNKNOWN ( ) 09 OTHERNE WRAP <br /> (t)1 0902 VOTHERINYL WRAPPING ( ) 03 CATHODIC <br /> VI PIPING <br /> A. ABOVEGROUND PIPING= ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f ) 03 GRAVZT <br /> (CHECK APPROPRIATE BOX(ESl ( ) 04 PRESSURE f 1 05 SUCTION ( 1 06 UNKNOWN (J(�1 07 NONE <br /> B. UNDERGROUND PIPING ( ) O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (RI 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (Xl 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 7 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS (A) 07 PRESSURE TEST UM 09 NONE ( ) 10 OTHER' <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CA$# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 ( ) 02 ( 1 03 <br /> [ ) 01 ( ) 02 ( ) 03 <br /> f i 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> [ ) O1 ( ) 02 ( ) 03 <br /> f 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> • 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 /> PERSO ILING ( G TUBE) PHON /ARE COD <br /> FOR LOCAL AGENC USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON <br /> PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID A <br /> ( ) 01 YES ( ) 02 NO <br /> KSC04-070185 (10/18/85) <br /> PAGE 2 <br />