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STATE I0 NUMBER 00000036871005 CONTAINER CONSTRUCTION E. ( ) OS RUBBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING t ) 05 GLASS LINING ( J 07 UNLINED (X) 08 UNKNOWN t ) 09 OTHER: F. ( ) 01 POLY€THLENE WRAP ( ) 02 VINYL WRAPPING ( ? 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 102 CONCRETE-LINED TRENCH' ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN _LJSr07 NONE B.-UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LIMED TRENCH (X) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( } 07 NONE VII LEAK DETECTION wr O1 VISUAL 02 STOCK INVENTORY ( D 04 VAPOR SNIFF WELLS ( D 05 SENSOR INSTRUMENT ) 06 GROUND W ER MONITORING WELLS (X 07 PRESSURE TEST t ) 09 NONE ( 1 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STORED 01 ( ) 02 t 1 03 [ D 01 ( ) 0.2 ( ) .03 ( } 01 ( ) 02 f ) 03 ( ) 01 ( ) 02 f ) 03 01 ( ) 02 ( } 03 ( l 01 ( ) 02 ( ) 03 3 01 ( ) 02 ( ) 03 # D 01 ( D 02 ( ) 03 t } 01. ( } 02 ( ) 03 ( ) 01 ( D 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO THIS FORM H!31 BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND: TO THE BEST OF MY KNOWLEDGEP IS TRUE AND CORRECT. PEPSO NG (SIG U PHON@ W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # r ( ) O1 YES ( ) Q2 NO z5__9 KSC04-070183 (10/18/85) ' PAGE 2 l