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CONTAINER CONSTRUCTION STATE 20 NUMBER 00000057633001 <br /> E. f 1EOIPOLYETHLENE <br /> BER LINED f 1 02 ALKYD LINING ( l 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> UNLINED (X) 06 UNKNOWN ( 1 09 OTHERF. f l WRAP f 1 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN f 1 OS NONE <br /> TAR OR ASPHALT ( 1 09 OTHER <br /> VI PIPING <br /> E <br /> OVEGROUND PIPING: O1 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> HECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION f 1 06 UNKNOWN f 1 07 NONE <br /> DERGROUND PIPING- f ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY <br /> HECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> f 1 06 GROUND WATER MONITORING WELLS f 1 07 PRESSURE TEST ( 1 09 NONE 1 1 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 CAS# (IF KNOWN) <br /> STORED STOPED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> f ) 01 ( 1 02 ( 1 03 <br /> ( ) <br /> 01 f 1 02 ( ) 03 <br /> ( ) O1 ( 1 02 f 1 03 <br /> ( l 01 f ) 02 ( 1 03 <br /> ( ) 01 ( ) OE ( ) 03 <br /> f ) <br /> 01 f ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 f 1 02 ( 1 03 <br /> ( ) O3 ( 1 02 ( 1 03 <br /> [ ) al ( 1 02 f ) 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 /> 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 COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DAT! LOCAL PERMIT IO # <br /> f ) O1 YES ( ) 02 NO <br /> KSC04-070185 (10/18/85) PAGE 2 <br />