Laserfiche WebLink
STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1"01 RUBBER LINED ( 1 02 ALKYD LINING 1 1 03 EPDXY LINING 1 1 04 PHENOLIC LINING l 1 05 GLASS LINING <br /> 1x1 07 UNLINED ( 1 OB UIIKNOWN 1 1 09 OTHER: <br /> F. 1 1 01 POLYETHLEHE WRAP 1 1 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION ( 1 04 IAIKHOWN 1,,4 05 NONE <br /> ( 1 06 TAR OR ASPHALT i 1 09 OTHER: <br /> VI PIPING _ <br /> A. ABOVEGROUND PIPING: 1 1 01 DOUBLE—WALLED PIPE 1 1 02 CONCRETE—LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST 1 ) 04 PRESSURE l 1 05 SUCTION 1 1 06 UNKNOWN ( 1 07 NONE <br /> B. IAIOERGROU110 PIPING: ( 1 01 DOUBLE—WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH l 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIESI Ix 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN 1 1 07 NONE <br /> VII LEAK DETECTION <br /> 1 1 <br /> 01 VISUAL 14 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS ( 1 05 SENSORINSTRUMENT <br /> 1 1 06 GROUIM WATER HONITORING WELLS 1 1 07 PRESSURE TEST l 1 09 NONE 1 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> If YOU CHECKED YES TO IV•P YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASK IIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 1 1 O1 ( 1 02 1 1 03 I I I <br /> ( ) Ol ( 1 02 ( 1 03 I I I I I I I <br /> 1 ) Ol ( ) 02 1 ) 03 <br /> l 1 01 ( ) 02 ( ) 03 <br /> ( 101 ( ) 02 ( ( OSI I I I I I I I I I I I I <br /> 1 1 Ol 1 1 02 l 1 03 <br /> ( ) 01 ( ) 02 ( ) 031111111111111 <br /> 1 1 01 ( ) 02 11 03 Ll I I I I I I I I I I I <br /> I ) O1 I ) 02 1 1 03 <br /> I ) Ol _-1-1 02_ 1 1 03 I I I <br /> IS COIITAINER LOCATED ON AN AGRICULTURAL FARM? 1 1 01 YES 1X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UDDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br /> P_c F GNATu E ) PHONE WiAR CODE <br /> _ <br /> e Y ro Lo 4l S <br /> FO L CAL AGENCY USE ONLYu <br /> •D"P+ISTpa T:�� E++CY CITY COD[ COVNTYCOOt <br /> - -�0- - Lb aQ <br /> CA- - 3-cl--- -- - - - --- -- - <br /> CO•+'ACT ELCCN --_ - —_ pN EOW/AR COD[ <br /> T -_ <br /> DATE OF LAST INSPECTION ISN COMPLIANCE _IIY'FEKMIT APPROVAI DATE TRANSACTION DATE II LOCAL PERMIT TO 8 <br /> cl les <br /> ASC04-079185 l PAGE 2 <br />