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S. .. <br /> STATE ID NUMBER 00000011279001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( l 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f 102 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN g{-17 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN f 1 07 NONE <br /> VII LEAK DETECTION <br /> I <br /> bW 01 VISUAL (X) 02 STOCK INVENTORY f l 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> `f-) 06 GROUND WATER MONITORING WELLS ¢S) 07 PRESSURE TEST ( ) 09 NONE ( l 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) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 - ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IIS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f 1 01 YES (XI 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 SLING (SIGNATUR PHONE WAR E CODE� Q <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRA,1LNG AGF"Y CITY CODE COUNTY CODE <br /> J d L� <br /> CONTACT, PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> _ _ G ( ) 01 YES ( ) {0022,.NO <br /> KSC04-070185 (10/18/85) m)%o' s" � PAGE 2 <br />