Laserfiche WebLink
STATE ID NUMBER 00000006323001 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( l 05 SUCTION ( 7 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING= ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION f ) 06 UNKNOWN ( ] 07 NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL (J� 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> f ) 06 SROUNC�ICTE OR�URIRUWECCS'T ) 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 REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> ( ) <br /> 01 ( ) 02 f ) 03 <br /> ( 1 Ol f ) 02 ( ) 03 <br /> ( 1 01 ( 1 02 f 1 03 <br /> " ) <br /> 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( 7 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> I ) Ol ( ) 02 ( ) 13 <br /> ( 1 Ol ( 7 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 f ) 03 <br /> f ) 01 ( l 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> FIS LOCATED ON AN AGRICULTURAL FARM? ( 1 01 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 /> PERSO➢b PALING (SSGNATUREI PHONE W/ARCA CO O 0s_/ <br /> �� <br /> FOR LO AL AGENCY USE ONLY <br /> ADMINISTRATING AGENCYCITY CODE COUNTY CODE <br /> SAA/ s;M /N LccI4L t-M&At. Di 'cT <br /> CONTACT PERSONIPHONE W/AREA CODE <br /> �n <br /> DATE OF LAST NSPEy TION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> X/7 f 7 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> • <br /> 0 <br />