Laserfiche WebLink
rnuoTRll!`TTnu <br />0 <br />STATE ID NUMBER 00000053870002 <br />UON IHl INCK VUii'1 _.I- <br />E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE <br />(XI 06 TAR OR ASPHALT ( ) 09 OTHER: <br />V I r 1 r 1110 <br />A. ABOVEGROUND PIPING: ( 1 01 DOUBLE -WALLED PIPE ( 1 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) l ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. UNDERGROUND PIPING: f ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />vTT I CAI( nF:TFrTTnN <br />( ) 01 VISUAL (X) 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER) <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />—i xnu mOT ecnilTovn TO [OMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( 1 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 I <br />( 1 01 <br />f ) 02 <br />( ) 03 <br />( ) 01 <br />t 1 02 <br />( ) 03 <br />( 1 01 <br />f 1 02 <br />( ) 03 <br />( 1 01 <br />( 1 02 <br />( ) 03 <br />( 1 01 <br />( 1 02 <br />( ) 03 <br />( l 01 <br />( 1 02 <br />( ) 03 <br />( ) 01 <br />( 102 <br />( ) 03 <br />( 1 01 <br />( 1 02 <br />( ) 03 <br />* CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />[S CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br />TUTS FORM HAS RFFN rnMP1 FTFD UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />)ERSOy1 �FILI N^ (S' ATU P.E)� PHONE W/.AREA CODE <br />{u 1-699-c�a3 <br />ac�S <br />:no InrAl ArFNCY (ISE ONLY <br />AOMINISTRA INS AGENCY <br />U //��� y^y <br />CITY IDE <br />7 <br />COUNTY CODE <br />S <br />COFCT <br />PERSCODE'7/ci <br />-3DAOR <br />LAST INSPECTION <br />IN COMPLIANCE PERMIT <br />APPROVAL DATE TRANSACTION DATE <br />LOCAL PERMIT ID # <br />( ) 01 YES ( ) 02 NO <br />HSC04-070185 (10/18/85) <br />PAGE 2 <br />