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• STATE ID NUMBER 00000021368001 <br /> i <br /> INER CONSTRUCTIONol BBER LINED( ) 080UNKNOWN LINING OTHER3 EPDXY LINING04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> NED <br /> 6LTARHORNASPHALT E WRAP (()1 02 VINYLWRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN f 1 05 NONE <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH 03 GRAVITY <br /> ( 1 <br /> ON (X) 06 UNKNOWN ( ) 07 NONE <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTI <br /> B. UNDERGROUND PIPING; ( ) O1 DOUBLE-WALLED PIPE ( ) ON CON;R 06EUNKNOWNTREN 7H I 3 GRAVITY <br /> 07NONE <br /> (CHECK APPROPRIATE BOX ES) 1-X1 04 PRESSURE (X) <br /> VII ENT <br /> LEAK DETECTION <br /> yq` 05 <br /> 010VIGROUNO(W4) 02 STOCK INVETOYAT ER MONITOR INGNWELLS ( 1 047V PPOSSUREFTESTLLS )(09 NONE <br /> ENSOR 10 OTINSTRHER: <br /> VIIF YOU CHEMDICDALES DCOMPOSITIONTO IV-F OFOP NOT REQUIREDIOcoMPSDREDNNDERGROUND CONTAINERS <br /> ETSECTION <br /> CU-.RENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) <br /> 01 f ) 02 ( ) 03 <br /> f ) Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) <br /> 01 f ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) 01 l ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> Q ) Ol ( ) 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 /> PHONE W/ARE��a <br /> PERSON FILING ,(SiGNATURE ACq Q. <br /> FOR LOC�(•(ALy�(1�1ML�L AGENCY USE ONLY� CITY CODE __ <br /> COUN7TY CODE��� /J/� <br /> AD`I I�4�RATIN AGENCY /� L / '� <br /> S /Eppy �✓' �J [ J <br /> PHONE W/AREA CODE <br /> CONTACT P el <br /> C GO�J <br /> �l 'LLOCAL PERMIT ID # <br /> DATE OF L/{A$T INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> Ol YES ( ) 02 NO <br /> G L,7 <br /> PAGE i <br /> KSC04-070185 (10/18/85) P <br />