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STATE ID NUMBER 00000049996001 <br /> CONTAINER CONSTRUCTION <br /> E_ F 1 01 RUBBER LINED ( 1 02 ALKYD LINING f ) 03 EPDXY LINING ( ] 04 PHENOLIC LINING (X1 05 GLASS LINING <br /> ( ) 07 UNLINED ( 1 08 UNKNOWN t ) 09 OTHER: <br /> F. t ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT t 1 09 OTHER- <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE [ 1 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE f ) 05 SUCTION ( ) 06 UNKNOWN ( l 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL fX) 02 STOCK INVENTORY f#3 04 VAPOR SNIFF WELLS [ 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS [ 1 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 AAE NCT P.EGUIF°D TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAh'E1 <br /> STORED STORED <br /> E 1 01 ( ) 02 ( ) 03 <br /> [ ) <br /> 01 ( ) 02 ( 1 03 <br /> ( ) 01 f 1 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> f ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 [ ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> F l OI S 1 02 ( 1 03 <br /> ( 1 01 [ l 02 ( 1 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 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 /> PERSON .FALING (S$GNATU E PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIN I PATING�E`1CY CITY CODE COUNTY CODE <br /> CONTACT PE=SON PHONE W/A EA CODE <br /> e <br /> DATE OF LAST INSPECTION IN CQMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PEP.MIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> KSC04-070185 (10/18/85) PAGE 2 <br />