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STATE ID NUMBER 0000003540304i <br /> CONTAINER CONSTRUCTION <br /> E. t } 01 RUBBER LINED ( ) 02 ALKYD LINING t ? 03 EPDXY LINING ( ) 04 PHENOLIC LINING t ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER <br /> F. ( ) 0-1 FOLYETHLENE'WRAP ( ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> t ) 06 TAR OR ASPHALT t } 09 OTHER <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE—WALLED PIPE t ) 02 CONCRETE—LINED TRENCH ( l 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: { ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE { ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> d D 01 VISUAL f ) 02 STOCK INVENTORY t } 04 VAPOR SNIFF WELLS t } 05 SENSOR INSTRUMENT <br /> t 106 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE t ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> (X) 01 ( ) 02 ( ) 03 STEAM CLEANING RUNOFF <br /> ( ) 01 ( ) 02 ( ) 03 <br /> i 101 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> ( D 01 ( ) 02 ( ) 03 <br /> t l 01 ( ) 02 ( ) 03 <br /> t } 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) '03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> } 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t ) 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 /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> KSC04-070185 (10/18/85) PAGE 2 <br />