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Nano, "'0 STATE ID NUMBER 00000030256008 CONTAINER CONSTRUCTION E. l ) 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED [ ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETH LENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( l 09 OTHER: VI PIPING E ROUND PIPING: ( ) O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE ROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY APPROPRIATE BOX(ES) ( 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN (X) 07 NONE VII LEAK DETECTION MM 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( l 06 GROUND WATER MONITORING WELLS ( 07 PRESSURE TEST ( ) 09 NONE ( 1 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED ( ) 01 ( ] 02 ( ) 03 f ) Ol f l 02 ( 1 03 f l Ol ( l 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( l 01 ( 1 02 ( ) 03 ( 1 01 f 1 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( ) O1 ( ) 02 ( ) 03 ( ) 01 [ ) 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 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. (PERSON FILING (SIGNATURE /l /' n/) PHONE W/AREA CODE ILFOR LOCAL AGENCY USE ONLY (/J v(v/(/w/' O ADMI STRATIN AGENCY CITY CODE COUNTY CODE CONT&;7S PEPSON P ONE /AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ) 02 NO KSC04-070185 (10/18/85) PAGE 2 � y