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STATE ID NUMBER 00000000747002 CONTAINER CONSTRUCTION E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( l 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING l ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( l 05 NONE ( ) 06 TAR OR ASPHALT f 1 09 OTHER VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION (4fY O1 VISUAL (X) 02 STOCK IN ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( i 06 GROUND WATER MONITOR ZNG WELLS f ] 07 PRESSURE TEST f l 09 NONE ( ) 10 OTHER= 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) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED ( ) 01 ( 102 [ 1 03 ( ) Ol ( 1 02 ( 1 03 f 1 01 ( ) 02 ( 1 03 f ) 01 ( ) 02 ( ) 03 ( ) 01 f 1 02 ( ) 03 f 1 01 ( ) 02 ( ) 03 ( 1 01 [ ) 02 ( ) 03 [ ) 01 ( ) 02 ( ) 03 [ ) 01 ( l 02 ( ) 03 - f 1 01 ( 1 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. PCR O W , - FOR L AL AGENCY USE ONLY ACMINISTR ATIND AGENCYCITY CODE COUNTY CODE CONTACT PERSON PHONE AREA CODE �-�r/'� -7)(J(p7 DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID (+ ( ) 01 YES ( ) 02 NO KSC04-070185 (10/18/85) PAGE 2