Laserfiche WebLink
STATE IO NUMBER <br /> CbNTAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER LINED ( ) 02 ALKYO LINING f 1 01 EPDXY LINING 1 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> f 1 07 UNLINED ( ) OB UNKNOWN 1 1 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP l 1 02 VINYL WRAPPING 1 1 03 CATHOOI PROTECTION l 1 04 UNKNOWN f 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT 1 ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGP,OUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE l 1 05 SUCTION 1 1 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: f 1 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST 1 1 04 PRESSURE l 1 OS SUCTION l 1 06 UNKNOWN 1 1 07 NONE <br /> VII LEAK DETECTION <br /> L1 01 VISUAL 1 1 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> l 1 06 GP.DU101 WATER MONITORING WELLS l 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CNCCKEO YES TO IV-P YOU ARE NOT REQV:RED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL TDO NOT USE COMMERCIAL NAME) <br /> STORED STOP'EO <br /> N <br /> f l O1 ( 1 02 ( 1 OS ! I I <br /> ( 1 01 l l 02 ( ) 03 <br /> 1 1 <br /> 01 f 1 02 1 1 03 <br /> l 1 01 f l 02 f 1 03 <br /> f 1 Ol ( 1 02 1 1 03 <br /> ( 1 <br /> 01 1 1 02 1 1 01 <br /> 1 1 O1 11 02 1 1 03 <br /> ( 1 01 l ) 02 1 1 03 <br /> l 1 01 f ) 02 ( ) 03 <br /> f' f-1 O1l 1 02 ( 1 03 <br /> IS CI 0!LTAIHER LOCATED ON AN AGRICULTURAL FARM? f 1 O1 YES ( 102 NO <br /> PHIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND. TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br /> PIG /;VN (SSf�yATUiF) PHONE W/AREA CODE <br /> �/A/ yVli/72-ro <br /> FOR LOCAL AGENCY USE ONLY <br /> AOM7145 TPATINO AGENCY CITY CODE COUNTY CODE <br /> CONTACT PEGSON PNO NC W/ARCA CODE <br /> DATE OF l ST ig t'jC ON IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL /FRMIT ID R <br /> Ol Y!S f 1 0E NO <br /> ISC04-070185 <br /> PAGE 2 <br />