BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE I0 NUMBER 00000008496004 CONTAINER CONSTRUCTION E. f ) 01 RUBBER LINED ( 1 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. f ] 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( l 05 SUCTION (X) 06 UNKNOWN ( 1 07 NONE B. UNDERGROUND PIPING: ( 1 Al DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION (X) 01 VISUAL (X) 02 STOCK INVENTORY f l 04 VAPOR SNIFF WELLS l ] 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS 1 1 07 PRESSURE TEST ( 1 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU ARE NOT RE7UIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STOPED STORED l 1 01 ( 1 02 ( 1 03 II- f l 01 ( 1 02 ( 1 03 ( ) O1 ( 1 02 ( 1 03 ( 1 01 ( 1 02 ( 1 03 ( 1 01 ( 1 02 ( 1 03 ( } 01 ( ) 02 ( ) 03 t 1 Ol ( 1 02 ( 1 03 1 1 Ol f ) 02 ( ) 03 1 1 O1 f ) 02 ( ) 03 ( ) 01 ( 1 02 ( ) 03 ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PARSON F ING (SIGNAT E1 PX E W/jCODE FOR. LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY / CITY CODE COUNTY CODE CONT T PERSON P NE W/AREA CODE., Z /!O DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2