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STATE ID NUMBER 00000004180003 CONTAINER CONSTRUCTION E. t ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. f 1 01 POLYETHLEHE WRAP f ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT t 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING t ) Ol DOUBLE-WALLED PIPE ( 102 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 (X) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( l 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT ( ] 06 GROUND WATER MONITORING WELLS t 1 07 PRESSURE TEST ( 1 09 NONE t ) 10 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 PPEVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED ( 1 01 t ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( l Ol t 102 t ) 03 ( oOl ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( 1 02 ( ) 03 ( ) 01 ( ] 02 ( 1 03 ( l el ( ) 02 f 1 03 ( 1 01 t ) 02 ( ) 03 ( 1 O1 f ) 02 ( 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 THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILIN^u IGNATURE) PHONE W/AREA CODE 0.FOR LOCAL AGENCY USE ONLY ADMI ST RATING AGENCY CITY CODE COVNTY CODE �/ 1 r CONT T PERSON PH E W/AREA CODE — 9 7 DATE OF LA INSPECTION ItLA tNO APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # !02 PAGE 2 KSC04-070185 (10/18/85)