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\.. N./ <br /> STATE ID NUMBER 00000033501001 <br /> CONTAINER CONSTRUCTION <br /> E. l 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f 7 05 GLASS LINING <br /> f ) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER- <br /> F. ( ) 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION f ) 04 UNKNOWN f 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING• ( ) 01 DOUBLE-WALLED PIPE ( 1 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 BOXES) ( ) 04 PRESSURE ( 7 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> s( 1 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> f ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-P YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (OO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) <br /> al I 102 ( 1 03 <br /> ( ) 01 f ) 02 ( 1 83 <br /> ( 1 O1 ( ] 02 ( 1 03 <br /> ( 1 O1 ( 1 02 ( ) 03 <br /> ( 1 Oi ( ] 02 ( 1 03 <br /> ( ) O1 ( 1 02 ( ) 03 <br /> ( 1 01 ( 102 ( ) 03 <br /> [ ) 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 f ) 02 ( 1 03 <br /> ( I O1 ( l 02 ( ) 03 <br /> R CHECK STATE BOARD CHEMICAL CODE LISTING FOR ,POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? (X) 01 YES ( ) 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 COOK <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 1 ) <br /> 01 YES [ ) 02 NO <br /> KSC04-070185 (10/18/85) PAGE 2 <br /> ``/ �� <br />