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0 <br />STATE 10 NUMBER 00000062853001 <br />Mali a W-19 a 91:6 2�91 9 &12 m"My a OR <br />E. t J 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING 04 PHENOLIC LINING 0 GLASS LINING <br />(X,) 0,7 UNLINED ( ) 09 UNKNOWN 019 OTHER: <br />F. 01 POLYETHLENE WRAP 02 VINYL WRAPPING 03 CATHODIC PROTECTION 04 UNKNOWN (X) 05 NONE <br />06 TAR OR ASPHALT 09 OTHER: <br />PIPING <br />A. ABOVEGROUND PIPING: t D 01 DOUBLE -WALLED PIPE ( ) 02 CONCRUE-LINED. TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ESI 04 PRESSURE 05 SUCTION 06 UNKNOWN 07 NONE <br />B. UNDERGROUND PIPING: 01 DOUBLE -WALLED PIPE 02 CONCRETE -LINED TRENCH 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) 04 PRESSURE' t 05 SUCTION f D 06 UNKNOWN (,,) 07' NONE <br />VII LEAK Q,IETECTION <br />f 01 VISUAL (X) 02 STOCK INVENTORY 04 VAPOR SNIFF WELLS 05 SENSOR INSTRUMENT <br />06 GROUND >WATER MONITORING' WELLS 07 PRESSURE TEST 09NONE10 ETHER: <br />VIII CHEMICAL COXPOSITIUN Of MATERIALS STORED IN UNDERGROUIND C,GNTAIHERS <br />IF YOU CHECKED YES TO IV -P YOU ARE NOT REQUIRED TO COMPLETE THIS Stt-nOw, <br />CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />STORED STORED <br />CHECK STATE � Bwb, CHEMICAL ZODE LISTING FOR POSSIBLE SYNONYM <br />IS GDNTAIN R LOCATED ON AN AGRICIULTIMAL FARM? ( 1 01 YES I -X) 62 No <br />2MA#JjjM; M_—WEEN/COMPLETED twbu � THE PENALTY OF PE 3W OF MY KNOWLEDGE) IS TRUE AND CORRECT. <br />ONE WAREA CODE <br />ADMZNZS'rPAT,ING AGENCY CITY CODE lCOUNTY CODE <br />CONTACT4 ERS <br />PS0c &rA (JA to 'PHONE W/AREA CODE <br />y1r— <br />DATE OF LAST INSPECTION' IN COMPLIANCE PERMIT APPROVAL DATE :TRANSACTION DATE LOCAL PERMIT 10 # <br />3_-2(9_y& 1 ( ) 01 YES 02 NO _� I <br />KSC04-07-0185 111D/18/65) <br />PAGE 2 <br />01 <br />02 <br />03 <br />01 <br />02 <br />1 1 P3 <br />01 <br />02 <br />( ) 63 <br />01 <br />t D 02 <br />( ) 0-3 <br />01 <br />02 <br />( ) 03 <br />ol <br />( ) o? <br />( ) 03 <br />02 <br />o:s <br />01 <br />f D 02 <br />03 <br />ot <br />0,2 <br />CHECK STATE � Bwb, CHEMICAL ZODE LISTING FOR POSSIBLE SYNONYM <br />IS GDNTAIN R LOCATED ON AN AGRICIULTIMAL FARM? ( 1 01 YES I -X) 62 No <br />2MA#JjjM; M_—WEEN/COMPLETED twbu � THE PENALTY OF PE 3W OF MY KNOWLEDGE) IS TRUE AND CORRECT. <br />ONE WAREA CODE <br />ADMZNZS'rPAT,ING AGENCY CITY CODE lCOUNTY CODE <br />CONTACT4 ERS <br />PS0c &rA (JA to 'PHONE W/AREA CODE <br />y1r— <br />DATE OF LAST INSPECTION' IN COMPLIANCE PERMIT APPROVAL DATE :TRANSACTION DATE LOCAL PERMIT 10 # <br />3_-2(9_y& 1 ( ) 01 YES 02 NO _� I <br />KSC04-07-0185 111D/18/65) <br />PAGE 2 <br />