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• STATE ID NUMBER 00000038113002 <br />CONTAINER CONSTRUCTION <br />[ 1(RUBBERINED(X 7 ) 0UNKNOWN 2 ALKYD L <br />1 (N )N09 OTHER: 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) OS GLASS LINING <br />07 <br />NED <br />E 0 <br />F ( 1(01 POLYETHLENE WRAP <br />([))02 VINTL ( ] 03 CATHODIC PROTECTION (X) 04 UNKNOWN l 1 05 NONE <br />VI PIPING 02 <br />A (CHECKRAPPROPRIATE BOX[ES) ( [ 01104 PRESPE <br />SOR ELED 1205 SUCTION L0(N )R 06EUNKNOWNTR (H 1H 07(NONE3 GRAVITY <br />B. UNDERGROUND PIPING: ( 1 1 DOUBLE -WALLED PIPE 02 4 PRESSURE (�2 05 SUCTION CONCRETE -LINED 6UNKNOW_LINEDNTREN �H 07(NONE3 GRAVITY <br />(CHECK APPROPRIATE BOX(E51 <br />VII LEAK DETECTION <br />( ( 010VVISROUNO(X) 02 STOCK <br />MONITINVENTORING R LS ([)1007VPRESSUREAPOR F TESTEES 1(09 NONE05 ) INSTRUMENT OHER: <br />VI iF vCHcMc eo ves COMPOSITIONTO IV -F OFOFNOT R MATERIALS <br />cS STORED SECTION <br />NIOUNDERGROUND CONTAINERS <br />OU <br />CURRENTLY PREVIOVSLY DELETE CAS# (IF KNOWN) <br />CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />STOPED STORED <br />( ) 01 ( ) 02 ( ) 03 <br />( ) 01 ( 1 02 ( ) 03 <br />l ) 01 ( ) 02 ( ) 03 <br />( 1 01 ( 1 02 ( ) 03 <br />( ] 01 ( ) 02 ( ) 03 <br />( 1 01 ( ) 02 ( ) 03 <br />( 7 01 ( ) 02 ( ) 03 <br />f 1 01 ( 1 02 ( 1 03 <br />( > 01 ( 1 02 ( 1 03 <br />( 1 01 l 1 02 ( 1 03 <br />CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 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 />PHONE W/AREA CODE <br />PEPSCDI-5ILING (SIGNATUPF) n /,i /I %/InQl f <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY 1 1) P <br />OONP.S N U /f� <br />Il�1i <br />CC <br />DATE OF LAST INSPECTION IN COOILYIIE SCEP ) 02 NO <br />PERMIT APPROVAL DATE <br />P <br />E <br />LBjRY 0q65 -3 <br />TRANSACTION DATE <br />KSC04-070185 (10/18/85) <br />0 0 <br />COUNTY CODE <br />LOCAL PERMIT IO # <br />PAGE 2 <br />