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STATE IO NUMBER 00000035349001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> t ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION f ) 04 UNKNOWN ( ) 05 NONE <br /> (X) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING' ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 O1 VISUAL ( ) 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> f ) Ob GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> f ) <br /> 01 ( ) 02 ( 1 03 <br /> ( ) 01 f ) 02 ( 1 03 <br /> ( 1 <br /> 01 ( ) 02 ( 1 03 <br /> f l 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ] 01 ( ) 02 ( ) 03 <br /> ( l <br /> 01 f 1 02 f ) 03 <br /> ( 1 <br /> 01 ( ] 02 f ) 03 <br /> (. 1 01 ( 1 02 ( ) 03 <br /> ( l 01 ( ) 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 /> PEPSON F NO SIGN E) PHONE W/AREA CODE <br /> 00 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY DfST CITY CODE COUNTY CODE <br /> 57;or IV (Q_a / /J Lo c.Pot f_ i c4l:f <br /> CONTACT PERSON PHONE W/AREA CODE <br /> P 2.0 1 .- 5,X3-3/ 8/ <br /> DATE OF LAST IQNSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 7�0 7 <br /> 01 YES ) 02 NO <br /> 4 <br /> KSC04-070185 (10/18/85) - PAGE 2 <br />