BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE 20 NUMBER 00000037848001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING 1 1 04 PHENOLIC LINING ( 1 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER- F. l ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 103 CATHODIC PROTECTION ( 1 04 UNKNOWN f ] 05 NONE (X) 06 TAR OR ASPHALT ( ] 09 OTHER= VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING ( ) O1 DOUBLE-WALLED IPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) f ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION ( 1 01 VISUAL (X) 02 STOCK INVENTORY ( �")/�04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS UU 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 OAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED ( 1 OS ( ) 02 ( ) 03 1 1 Ol ( ) 02 ( ) 03 ( 1 Ol ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 ( 1 Ol ( l 02 ( ) 03 ( 1 01 f 1 02 ( ) 03 ( 1 O1 [ ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( ) 01 f 1 02 ( ) 03 ( 1 01 f 1 02 ( ) 03 R CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM?, ( ) 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. PER N FIL O (SIGNATURE) PRONE W/AREA CODE o 9 - 9 3 - 3s i FOR LOCAL AGENC USE ONLY ADMIHISTRATIN AGENCY CITY CODE COUNTY CODE CONTA T PERSON PXONh W/AREA CODE DATE OF 1. ST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ] 02 NO HSC04-070185 (10/18/851 PAGE 2