Laserfiche WebLink
STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: ' <br /> F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION ( l 04 UNKNOWN f l 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOABLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE 05 SUCTION f 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> f 1 01 VISUAL 02 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND—WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <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 (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ) 01 ( ) 02 ( ) 03 I I I <br /> 1 1 <br /> 01 1 1 02 f l 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> ( 1 Ol l 1 02 ( ) 03 <br /> ( ) <br /> al ( ) 02 f ) 03 <br /> ( 1 01 ( ) 02 l ) 03 <br /> f ) 01 ( ) 02 ( ) OS <br /> ( 1 <br /> 01 ( ) 02 l ) 03 <br /> ( 1 <br /> 01 f ) 02 ( ) 03 <br /> ( ) 01 f 1 02 f 1 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES 2 NO <br /> THIS FORM HA EN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERS N F L (SIG ATUF ) PHONE W/AREA CODE <br /> O9-f/ -G32 7 <br /> FOR LOCAL AGENCY USE ONLY <br /> AOMINISTP0.TI N3 AGENCY �� CITY CODE COUNTY CODE <br /> 1 91 <br /> oeuct� lam/ ,JE� I ar <br /> CONTAr,T ''P//ER N PN E W/ARCA CODE <br /> mM <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> f l 01 YES f 1 02 NO <br /> HSC04-070185 - PAGE 2 <br />