Laserfiche WebLink
%01 ..i <br /> STATE ID NUMBER 00000021696001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) Ol RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING ( ] 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION f 1 04 UNKNOWN [ 1 05 NONE <br /> (X) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE f 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> BJ UNDERGROUND PIPING ( ] 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( 1 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( l <br /> 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> Il ( ) 06 GROUND WATER MONITORING WELLS [ ) 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 PPEVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f ) Ol ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 f ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 l 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> l ) <br /> al ( ) 02 ( ) 03 <br /> 01 f ) 02 ( ) 03 <br /> ( 1 <br /> 01 f ) 02 ( ) 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/I5 TRUE AND CORRECT. <br /> PCR N FIL IGNATUR )C�/�i.�' PHONE W/AREEA CODE <br /> FOR LOCAL l/A/GGENCY USE ONLY ds� <br /> ADMI NiSTRATiNG AGENCY CITY CODE COUNTY CODE <br /> CONT T PERSO PH E W/ REA CODE <br /> a(99 S s <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> f I 01 YES ( ) 02 NO <br /> • MSC04-070185 (10/18/85) PAGE 2 <br /> 1 �� <br />