Laserfiche WebLink
STATE IG\NUMBER 00000061845002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED C ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING [ ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION f 104 UNKNOWN f 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ] 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (?{J 04 PRESSURE f ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL (X) 02 STOCK INVENTORY [ ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ,I <br /> ( ) 06 GROUND WATER MONITORING WELLS 07 PRESSURE TEST ( ) 09 NONE ( Q 10 OTHER: �Y\Q. Lehk oe�H Gt0 <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS% (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( 1 03 <br /> 1 ) 01 ( ) 02 ( ) 03 <br /> f ) 01 C J 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> ( 1 <br /> 01 [ 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( 1 03 <br /> ( I <br /> 01 ( )' 02 ( ) 03 <br /> f l O1 ( ) 02 1 1 03 <br /> f 1 <br /> 01 ( ) 02 1 ) 03 <br /> ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> P[ ON FILING (SIGNAT 7 ♦ PMO N! W/AREA Cp DE 3� <br /> FOR LOCAL AGENCY USE ONLY /%�J <br /> AD MZ NIST RATINGAOE NCV CITY CODE COUNTY CODE <br /> �► La e"4 <br /> CONTACT PER�9N <br /> U PHONE W/AREA CODE <br /> /� <br /> DAT! OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DAT! LOCAL PCRMIT ID % <br /> ap' ( ) Ol YES ( 7 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />