BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

CONTAINER CONSTRUCTION STATE ID NUMBER 00000004155001 E. f 1 01 RUBBER LINED ( ) 02 ALKYO LINING [ ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f ) 05 GLASS LINING l ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F- ( ) 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION f ) 06 TAR OR ASPHALT 0 (X) 04 UNKNOWN ( ) 05 NONE ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING. f 1 O1 DOUBLE-WALLED PIPE ( ) 02 COEE-LINED TRENCH ( 7 03 GRAVITY (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE f ) OS SUCTION ( UNKNOWN f I OJ NONEB. UNDERGROUND PIPING: ( ) O1 DOUBLE-WALLED PIPE ( ) 02 COE-LINED TRENCN ( 1 03 GRAVITY (CHECK APPROPRIATE BOX(E37 ( 1 04 PRESSURE (X1 OS SUCTION ( UNKNOWN ( ) 07 NONE VII LEAK DETECTION IX) 01 VISUAL ( 7 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS [ ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV•F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# IIF KNOWN) STORED STORED CHEMICAL IDD NOT USE COMMERCIAL NAME? ( ) 01 f ) 02 ( ) 03 ( ) 01 ( ) 02 f ) 03 ( 7 01 ( ) 02 [ ) 03 - ( ) 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( 7 03 ( 1 01 ( ) 02 ( ) 03 f ) Ol ( l 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) Ol f ) 02 ( ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X1 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 INSPlCTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ZO # ( ) O1 YCS < ) 0 NNO KSC04-070185 (10/18/85) PAGE 2 S