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STATE ID NUMBER 00000004252001 CONTAINER CONSTRUCTION E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING ( 1 04 PHENOLIC LINING [ ) OS GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( l 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION 1X1 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING l ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE (xl 05 SUCTION (.0 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE (X) 05 SUCTION ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION „( 1 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND NATER MONITORING WELLS ( 1 07 PRESSURE TEST ( 109 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 (00 NOT USE COMMERCIAL NAME) STORED STORED ( ) O1 ( ) 02 ( 1 03 ( 1 Ol ( 1 02 ( ) 03 f ) 01 ( ) 02 l ) 03 ( ) 01 [ ) 02 ( ) 03 ( ) Ol ( 1 02 ( ) 03 f ) 01 ( ) 02 ( 1 03 ( ) O1 ( ) 02 ( 1 03 ( ) Ol f ) 02 ( ) 03 ( ) Ol [ ) 02 ( ) 03 l 1 01 f 1 02 ( ) 03 R CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO THIS FORM MAS OMP ETED ER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. PERSON LI N PM ;E W/ ERA ODC / FOR LOCAL AG Y USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREACODE 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 \mmof