Laserfiche WebLink
CONTAINER CONSTRUCTION STATE ID NUMBER 00000005685001 <br /> E. ( 1 01 RUBBER LINED f ) 02 ALKYD LINING ( l 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> f ) 07 UNLINED ( ) 08 UNKNOWN (X) 09 OTHER: TAR <br /> F. ( ) 01 POLYETHLENE WRAP ( 7 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X1 04 UNKNOWN ( ) 05 NONE <br /> f 7 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN f ) 07 NONE <br /> _. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH (Xl 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN f 107 NONE <br /> VII LEAK DETECTION <br /> f 1 <br /> 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 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 RERUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> f ) Ol ( ) 02 [ ] 03 <br /> ( ) Ol ( 7 02 f 1 03 <br /> 1 1 01 ( ] 02 f ) 03 <br /> f 7 Ol ( ) 02 ( ) 03 <br /> f l 01 ( 1 02 ( ) 03 <br /> f 1 O1 ( ) 02 f ) 03 <br /> 02 ( ) 03 <br /> ( 1 01 t ) 02 f 1 03 <br /> ( 7 <br /> al ( 1 02 f 1 03 <br /> f ) 01 ( ) 02 1 ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) Ol YES (X) 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 /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> TACT PERSON PHONE W/AREA CODE <br /> 0 LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 1 ) Ol YES <br /> PAGE 2 <br />