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qSTATE ID NUMBER CONTAINER CONSTRUCTION E. ( 1 01 RUBBER LIMED f ) 02 ALKYD LINING { ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED `yr 08 L1r{F{NOWN ( } 09 OTHER F. i ) 01 POLYETHLENE WRAP I ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION k) 04 UNKNOWN ( ) 05 NONE i ) 06 TAR OR ASPHALT [ ) 09 OTHER VI PIPING - A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LIKED TRENCH ( ) 03 GRAVITY {CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN P<C 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) [ ') 04 PRESSURE 00 05 SUCTION { ) 06 UNKNOWN f ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (2SL-02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS—[ ) 05 SENSOR INSTRUMENT _— ( ) 06 GROUND WATER MONITORING WELLS ( (7 07 PRESSURE TEST ( ) 09 NONE t ) 10 OTHER: i VII rMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS ?r' -ji CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION � - - - - — CURRENTLY PREVIOUSLY DELETE CASH (IF KNOWNI CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED f ) 01 f 1 02 O 03 I_ II II II II II II _ ( ) 01 ( 1 02 [ 1 03�J-1 ( ) 01 i } 02 ( ) 03 ( ) 01 f 302 t ) 03 1 1 1 1 1 I I I 1 I 1 1 ( ) 01 c ) 02 f ) 03 I—I I I I — ( ) 01 ( ) 02 ( ) 03II1 1A_IILLLII _. ( ) 01 1 1 02 ( ) 03 I l I I I l I-J__LJ_1—l. l -----� f ) 01 t ) 02 I ) 03 I ' Ll f ) 01 ( ) 02 ( ) 03 �� --- - -- -- -ANTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 01 YES [W _02 NO S FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. -SqA FILING (SIGNATURE) PHONE W/AREA CODE IR LOCAL AGENCY USE ONLY ADMI31STRA JH3 AGENQY f CITY CODE COUNTY CODE L Ha CONTACT PEPStlF1 PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE�Tq�ANSACTI�ONDAT�ELOCAL PERMIT ID tt -�� ((�1 01 YES ( ) 02 NO KSC04-070.185 1 /L PAGE 2 r