BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE ID NUMBER 00000059849001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING 1 ) 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( l 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE f 102 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ] 05 SUCTION ( ) 06 UNKNOWN f 1 07 NONE VII LEAK DETECTION ( 1 Ol VISUAL f ) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT [ 1 06 GROUND WATER MONITORING WELLS [ ) 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV•F YOU ARE NOT REpUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL l00 NOT USE COMMERCIAL NAME) STORED STORED ( ) 01 ( ) 02 l ) 03 ( l 01 ( ) 02 ( ! 03 ( ) 01 ( ) 02 ( ) 03 ( ) O1 ( ) 02 ( ) 03 ( ) 01 ( ) 02 f ) 03 ( ) 01 ( ) 02 ( ) 03 ( 1 al ( ) 02 f 1 03 ( ) O1 ( ) 02 ( 1 03 f ) 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 f ) 03 ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? (X) 01 YES ( ) 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (SIGNATURE) PHONE 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 I0 L ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/851 PAGE 2