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' • • STATE IO NUMBER 00000005761003 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( 1 02 ALKYD LINING f ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f ) 05 GLASS LINING C ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION fX) 04 UNKNOWN f 1 05 NONE ( ) 06 TAR OR ASPHALT f ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS I 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO :V-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CUPFENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME ) STC2ED STORED ( 1 O1 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 f ) Ol ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 ( 1 Ol ( ) 02 ( ) 03 ( 1 Ol ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 t 1 Ol ( ) 02 ( ) 03 ( ) O1 ( ) 02 ( ) 03 ( ) 01 ( 1 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO '.. THIS FORH S BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. P.�R,SON F N GNATURE) PHO N! W/AREA CODE FOR L0 A AGENCY USE ONLY ADMINISTRATIN3 AGENCY Y�ST C27Y CODE COUNTY CODE s P,6 -Sp}kms 114 LLC tt L kA* CONTACT PERSON PHONE W/AREA CODE tZiC jRGD �SF� n) GATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # _ ��.$ ( ) 01 YES ( 1 02 NO KSC04-070185 (10/18/85) PAGE 2