Laserfiche WebLink
STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 101 RUBBER LINED (. ) 02 ALKYD LINING l 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> f ) 07 UNLINED ( 08 UNKNOWN 1 ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING kf 03 CATHODIC PROTECTION L0404 UNKNOWN 1 I OS NONE <br /> ( 1 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l ) 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE l 1 OS SUCTION f ) 06 UNKNOWN (XI 07 NONE <br /> B. UNDERGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE f O5 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> f ) 01 VISUAL (}(1_02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> 1 ) 06 GROUND TER MONITORING WELLS M 07 PRESSURE TEST ( ) 09 NONE ( ) 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 CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> 1 ) 01 ( ) 02 ( ) 03 <br /> 1 ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> 1 ) O1 ( ) 02 ( ) 03 _ <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> l ) 01 ( ) 02 ( ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? 1 ) 01 YES ) 02 ND <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND. TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON LI JS ONATUP PHONE W/ARCA CODE, <br /> FOP. LOCAL A ENCY USE ONLY (//J <br /> ADMI NI ST RATI N-IOENCY CITY CODE COUNTY CODE <br /> CONTA PERSON PHONE W/ARCA CODE <br /> Q <br /> DATE OF LAST INSPECTION INCOMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) O1 YES ( 1 02 NO <br /> NSC04-070185 PAGE 2 <br />