Laserfiche WebLink
STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> 01 RUBBER LINED ( ) 02 ALKYO LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( 1 07 UNLINED x.08 UNKNOWN l 1 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP 1 1 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION 00 04 UNKNOWN f ) 05 NONE <br /> f ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: I ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION [ 1 06 UNKNOWN L-0-07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( •1 04 PRESSURE 0 .05 SUCTION ( 1 06 UNKNOWN f 1 07 NONE <br /> VII LEAK DETECTION <br /> f ) <br /> 01 VISUAL OCr 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GROU ATER MONITORING WELLS ) 04 NONE ( 1 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 CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> f 101 ( 102 ( ' 031111111111 ( 11 <br /> ) 01 ( , 02 O 03 I I 1 Ll I I I I _Ll I <br /> f ) 01 1 ) 02 ( 1 03 <br /> ( 1 01 O 02 O 03 1 1 1 1 1 1 <br /> f 1 01 c 1 02 f 1 03 1 1 LH Ll 1 1 1 1 1 1 <br /> f ) 01 I. 1 02 ( ) 03 <br /> ( 101 [ 102 ( 103111IIIIIIIIII _ <br /> f ) O1 L 1 02 l ) 03 <br /> ( ) <br /> al ( ) 02 ( ) 03 <br /> 1 1 01 ( 1 02 ( ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f 1 01 YES ( 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 /> PERSO FILING ( GNATURE) C/7y OF T29G�/ PHONE W/AREA CODE <br /> sr, �µcaFr 020 9A 3 G G <br /> FOR LOCAL A ENCY USE ONLY <br /> ADM�'`�'S TRA TING AGENCY ' � �` CITY CODE COUNTY CODE <br /> J r1 I r �Ckl. IS _ .. <br /> CONTAC PERSON PHONE W/AREA COOK <br /> rA 5 <br /> DATE OF LAST INSPECTION SN COMPLIANCE PCOMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID S <br /> n/E1 YES�'7( l 02 NO <br /> HSC04-070185 ' " ' r - PAGE 2 <br />