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STATE ID NUMBER 00000035194001 <br /> CONTAINER CONSTRUCTION <br /> �01RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING i 1 05 GLASS LINING <br /> UNLINED (X1 08 UNKNOWN [ ) 09 OTHER: <br /> F. <br /> f) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNDWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT l ) 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND <br /> RAPPROPPIPING: <br /> BOX(ES) ( l 011040PRESSURELED( PIPE <br /> SUCTION CONlR06EUNKNOWN <br /> TREh()H07(NONE <br /> 3 GRAVITY <br /> C CK <br /> RIAT <br /> B. UNDERGROUND PIPING= ( 1 O1 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(E5) ( 1 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ] 07 NONE <br /> VII LEAK DETECTION <br /> [ )�) 076� <br /> SUAL 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> 10( GR <br /> ROU <br /> TOR ING WELLS ( ) 07 PRESSURE TEST JA* <br /> VIII CHEMICAL. COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED '(EES TO IV-F YOU .ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> CURAENTtY PREVIOUSLY DELETE C.AStt (IF KNOWN) <br /> STCF.ED STOPED <br /> t 1 01 ( 3 02 ( ) 03 <br /> ( ) 01 ( ) 02 f ) )3 <br /> ( l <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 C ) 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ] 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> =CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPL ED HIDER THE PEN T OF ERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PHONE My <br /> CODE 2- <br /> PEPSON FILING (SICNA E � _ L7 1� 3 <br /> FOR LOCAL AGENCY USE 0 Y <br /> Y [�� CITY CODE COUNTY CODE <br /> ADMIN ,4/V AGENCY fAJ �+, I A f n �1 y� <br /> JS ♦rfr1J /Y V PHONE W/AREA CODE <br /> CONTACT PE SO <br /> DATE OF LAST I�jSFECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> .s 1/�J. f ) 01 YES ( ) 02 NO <br /> PAGE 2 <br /> KSC04-070185 (10/18/85) <br />