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~� `1 STATE ID NUMBER 00000004406004 <br /> CONTAINER CONSTRUCTION <br /> Et ) <br /> UBBER LINED t 1 02 ALKYD LINING f ) 03 EPDXY LINING l ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> 7 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER:OLYETHLENE WRAP f ) 02 VINYL WRAPPING ( 7 03 CATHODIC PROTECTION [X] 04 UNKNOWN ( ) OS NONE <br /> 6 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 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 ( 106 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( l O1 VISUAL (X) 02 STOCK INVENTORY l ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> �Fiti'06 GROUND WATER MONITORING WELLS ( l 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CA$# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( l 01 ( ) 02 f ) 03 <br /> ( ) Ol f ) 02 ( 1 03 <br /> 1 ) Ol ( ) 02 l ] 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 ( 1 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) Ol ( ) 02 ( ) 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 /> P!RSON ILINO <S ATURU PHONE W/AREA CODE <br /> 909--%31 <br /> FOR LO AL AGENCY USE NLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CO NTA PERS N PHON W/A EA COOK <br /> DATE OF LAST INSPECTION IN COMPLIANC! PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> ( 1 <br /> 01 YES ( ) OS NO <br /> KSC04-070185 (10/18/85) PAGE 2 <br />