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a <br /> STATE ID NUMBER. 00000042134004 <br /> CONTAINER CONSTRUCTION <br /> E. t } 01 RUBBER LINED ( ) 02 ALKYD LINING (X) 03 EPDXY LINING ( 1 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> E ) 07 UNLINED ( 1 08 UNKNOWN ( ) 09 OTHER' <br /> F. l ) 01 POLYETiHLENE WRAP ( 1 02 VINYL WRAPPING { 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN i 3 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( J 09 OTHER. <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE—WALLED PIPE ( } 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX.(E5a ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> 5. UNDERGROUND PIPING- f ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH i 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX ES) i ) 04 PRESSURE (X) 05 SUCTION i ) 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL (X) 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> f ) 06 GROUND WATER MONITORING WELLS ( J 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO !V-F YOU APE NOT REQUIPED TO COMPLETE THIS SECTION <br /> CURRENTLY PFEVIOUSLY OFLETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) — — <br /> STOPED STORED <br /> i <br /> ( 1 01 ( 1 02 ( 1 03 <br /> f ) 01 f ) 02 ( } 03 <br /> E a 01 ( ) 02 ( ) (13 <br /> f ) O1 ( ) 02 ( } 03 <br /> ( 1 <br /> 01 ( ) 02 F ) 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> ( J 01 ( 1 02 ( } 03 <br /> ( ) <br /> 01 ( 1 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> ( ) 01 i ) 02 ( 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES iX) 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 /> AOMINISTPATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PEPSCN PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION INCOMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID ## <br /> ( ) 01 'YES ( ) 02 NO <br /> KSC04-070185 (10/18/85) PAGE 2 <br />