Laserfiche WebLink
STATE ID NUMBER 00000021890004 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING € ) 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f 9 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION HH-04 UNKNOWN ( 7 05 NONE <br /> (j() 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: { ) 01 DOABLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH { ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) C4 PRESSUP.E ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) i ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> (ab) 01 VISUAL ( J 02 STOCK INVENTORY i l 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> f ) 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 lOU CHECKED YES TO IV-F YOU ARE NOT REC.UIRED TO COMPLETE THIS SECTION <br /> CUPRENTLY PREVIOUSLY DELETE CASA (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL N'A'"E ) <br /> STORED STCrED <br /> V <br /> ( l 01 f ) 02 ( 1 03 _ <br /> ( ) 01 [ ) 02 ( 1 03 <br /> t ) <br /> 01 t ) 02 ( ) 03 <br /> f ) 01 t ) 02 t ) 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> ( ) <br /> 01 { ) 02 ( ) 03 <br /> ( ) 01 ( l 02 ( ) 03 <br /> ( 1 01 [ 1 02 ( ) 03 <br /> ( ) 01 t ) 02 ( 1 03 <br /> { ) 01 ( ) 02 { 1 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> LIS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES tX) 02 NO <br /> THIS FORM HAS BEEN COMPLETEJ UNDER THE PENALTY OF PERJURY ANDr TO THE BEST OF MY KNOWLEOGEs IS TRUE AND CORRECT. <br /> PERSON F L N ft <br /> NATUR PHO-W//AREA CODE L` l <br /> `{ IJP,/} � <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CCOE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES I ) 02 NO <br /> PAGE z <br /> )iSC04-070185 (10/18/85) <br /> 0 <br />