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STATE ID NUMBER 00000028627002 CONTAINER CONSTRUCTION E. ( 1 01 RUBBER LINED f ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN f ) 09 OTHER: F. ( l 01 POLYETHLENE WRAP l 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION (X) 06 UNKNOWN ( 1 07 NONE B. UNDERGROUND PIPING) ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE SOX(ES) t ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION ht 01 VISUAL ( ) 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT D NATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 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 PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STOPED ( ) 01 ( ) 02 ( ) 03 Li ( 1 01 ( ) 02 ( ) 03 ( 1 01 f 102 ( ) 03 ( ] 01 f 1 02 ( ) 03 ( 1 01 ( 1 02 ( ) 03 ( ) 01 f ) 02 ( ) 03 ( 1 01 t 1 02 ( 1 03 ( ) O1 ( l 02 ( 1 03 ( ) 01 1 ) 02 ( ) 03 ( ) 01 f ) 02 1 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 UNO R THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (SIGNATURE) IV PHONE W/AREA CODE o y — FOR LOCAL AGENCY USE ONLY ,/ v, ADMINISTRATING AOENC D�5/ CITY CODE COUNTY CODE s a �,4 Qu 7nl Loc�1C� CONTACT PEPSO G Z PHONE W/AREA CODE (�i G 7 DATE OF LP=T INSPEOT ON IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 4 01 YES ( ) 02 NO • KSC04-070185 (10/18/85) PAGE 2