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L � <br /> STATE I0 NUMBER 00000064653001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> f ) 07 UNLINED [XI 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> f ) 06 TAR OR ASPHALT ( l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH f 7 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH 0& 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 107 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 ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 f 1 02 ( ) 03 <br /> ( 1 01 [ 1 02 ( ) 03 <br /> [ ) O1 f 1 02 ( ) 03 <br /> f 1 01 ( 1 02 ( ) 03 <br /> 1 l <br /> 01 ( 1 02 ( ) 03 <br /> ( 1 01 f ) 02 ( 1 03 <br /> 1 ) <br /> 01 f ) 02 f 1 03 <br /> ( 1 01 f 1 02 ( ) 03 <br /> ( I O1 ( 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 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 /> PERSON FILING (SIGNATURE) PX9�E W/AREA CODE <br /> x 20 - 6 7 <br /> FOR LOCAL AGENCY USE ONLY <br /> AOMINI TRATA AGl NCY ! 'r CITY CQ[ COUNTY CODE <br /> WAIW <br /> CONTACT PERSON { V! PNO E qW/AREA CODE <br /> DAT[ OFLAST INSPECTION IN COMPLIANC! PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID k <br /> ( ) 01 Y!S ( ) <br /> 02 NO <br /> KSC04-070185 (10/18/85) PAGE 2 <br /> / <br />