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AOL <br /> STATE ID NUMBER 00000014332004 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED t ) 02 ALKYO LINING f :) 03 EPDXY LINING ( ) 04 PHENOLIC LINING t 3 05 GLASS LINING, <br /> (X) 07 UNLINED t ) 08 UNKNOWN ( ) 09 OTHER <br /> F. ( ) 01- POLYETHLENNE WRAP f ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION t ) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING f ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE t ) 05 SUCTION ( ) 06 UNKNOWN t ) 07 NONE <br /> B. UNDERGROUND PIPING: : t ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) t ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEA'K. DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS ( 105 SENSOR INSTRUMENT <br /> 06 GROUND WATER MONITORING WELLS d ) 07PRESSURE TEST f ) 09 NONE ( l 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES. TO IV--F YOU ARE NOT REgUIREO TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> (X) 01 ( ) 02 ( .} 03 MOTOR OIL <br /> t ) 01. ( ) 02 ( ) 03 <br /> ( ) 01 t ) 02 ( ) 03 <br /> E 3 03 ( ) 02 t ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( :) 02 . ( ) 03 <br /> t ) 01 ( ? 02 ( ) 03 <br /> f 'l 01 ( ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 01 YES (X) 02 NO <br /> THIS FORM AS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANDS TO THE BEST OF MY KNOWLEDGE: IS TRUE AND CORRECT. <br /> PERSO LING (SIG TU ) ` PHONE Wl EA CODE <br /> f <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIN STRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PEpRSON PH <br /> DE W AREA CODE <br /> �'t <br /> ATE OF LAST INSPECTION: IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 'YES ( ) 02 N0 <br /> HSC04-070185 (10018185): PAGE 2 <br />