Laserfiche WebLink
STATE ID NUMBER 00000049996002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ] 03 EPDXY LINING i ) 04 PHENOLIC LINING (X) CS GLASS LINING <br /> i ) 07 UNLINED ( l 08 UNKNOWN ( ) 09 OTHER. <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION f ] 04 UNKNOWN i ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT i ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING ( ) 01 DOUBLE—WALLED PIPE d ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: i ) 01 DOUBLE—WALLED PIPE d ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION f ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY (-X+ 04 VAPOR SNIFF WELLS ( ] 05 SENSOR INSTRUMENT <br /> i ) 06 GROUND WATER MONITORING WELLS i 1 07 PRESSURE TEST ( l 09 NONE ( ) 10 OTHER= <br /> _ 1 <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED 70 COMPLETE THIS SECTION <br /> CUPPENTLY PPEVIOJSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> d ) 01 ( ) 02 _; ( ) 03 <br /> ( ] 01 ( ) 02 [ ) 03 <br /> ( ] 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( l 03 <br /> d ) 01 ( ) 02 ( 1 03 <br /> i ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ] 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> �( CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( l 01 YES (X) 02 NO f_ <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON F LING (S:GN.ATQP'E) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINIS EATING AGENCY // / CITY CODE COUNTY CODE <br /> it <br /> 5-7 <br /> CONTACT PERSON ���� PHONE WlAREA COD <br /> E r 7 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMYT APPROVAL DATE TRANSACTION DATE `LOCAL PERMIT ID 4 <br /> ( ) 01 YES ( 3 02 NO <br /> HSC04-0701 5 (10/18/85) PAGE 2 <br />