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STATE ID NUMBER 00000064771001 CONTAINER CONSTRUCTION E. l 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) OS GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN 1 ) 09 OTHER: F. l 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING l ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE t ) 06 TAR OR ASPHALT ( 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 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 ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT '' ( ) 06 GROUND WATER MONITORING WELLS f 1 07 PRESSURE TEST ( ) 09 NONE ( ) 30 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 (00 NOT USE COMMERCIAL NAME) STORED STORED ( 101 ( 1 02 ( ) 03 f l O1 ( 102 ( ) 03 ( I O1 f ) 02 ( ) 03 ( 7 Ol f ) 02 ( 1 03 f 7 01 ( 7 02 ( ) 03 ( ) Ol ( i 02 ( ) 03 f 1 O1 ( 1 02 ( ) 03 ( ) 01 t ) 02 ( ) 03 f 1 --Olt ) 02 ( ) 03 ( ) 01 ( ) 02 f 1 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.23 PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSO ILI (SIGNATUR PHONE W/AREA CODE 7 -+ /p FOR LOCAL AGENCY USEtY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/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