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i STATE ID NUMBER 00000036003005 CONTAINER CONSTRUCTION 01 RUBBER LINED ( ) 02 ALKYD LINING [ ) 03 EPDXY LINING t 1 04 PHENOLIC LINING ( 1 05 GLASS LINING ( ) 07 UNLINED (X1 08 UNKNOWN ( ) 09 OTHER: F. [ ) 01 POLYETHLENE WRAP ( 7 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 7 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION l 7 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT f ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS :F YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CA$R (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STOPED STORED f ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( 1 03 ( 1 O1 ( ) 02 ( ) 03 [ ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 f l 01 ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 f ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 l ) 03 ( ) Ol ( ) 02 ( 1 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTLRRAL 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) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DAT: LOCAL PERMIT IO R ( ) O1 YES f ) 02 NO KSC04-070185 (10/18/85) PAGE 2