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STATE IO NUMBER 00000008332003 CONTAINER CONSTRUCTION E. ( D 01 RUBBER LINED ( ) 02 ALKYD LINING ( D 03 EPDXY LINING [ D 04 PHENOLIC LINING i ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( l 01 POLYETHLENE WRAP 1 ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( D 05 NONE (X) 06 TAR OR ASPHALT ( l 09 OTHER: VI PIPING A. ABOVEGROUND PIPING* ( ) 01 DOUBLE-WALLED PIPE [ ) 02 CONCRETE-LINED TRENCH f D 03 GRAVITY (CHECK APPRCPRIATE BOX(ES) ( ) 04 PRESSURE [ ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( 104 PRESSURE (X) 05 SUCTION 1 ) 06 UNKNOWN ( D 07 NONE VII LEAK DETECTION ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( D 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YCU CHECKEC YES TO IV-F YOU APE NOT PECUIRED TO COMPLETE THIS SECTION CURRENTLY PPE'J:C'JSLY DELETE CAStL (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STO=cD (X) 01 ( ) 02 ( ) 03 1 0 11 8 8 3 1 1 1 1 1 1 TOLUENE (METHYLBENZENErAROMATIC HYDROCARBON LOW ANALINE) ( l 01 ( l 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 f ) 01 ( ) 02 (' l 03 ( ) 01 [ ) 02 ( D 03 1 1 01 ( ) 02 1 ) 03 ( D O1 ( D 02 ( ) 03 f D 01 ( ) 02 ( D 03 f l 01 ( ) 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? 1 ) 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. PEP50N � SICihR PHONE WIAPE.A CODE FOR LOCAL AGENOaSE ONLY ADMIN'ISTP.AT NG AGENCY, A CITY CODE COUNTY CODE r CONTACT .ERSCN PHE W/AREA C0s7� LIST! DATE OF LAST INSPECTION IN COMPLIANCE PEPMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 3i ( ) 01 YES ( ) 02 NO KSC04-070185 (10/18/85) PAGE 2