Laserfiche WebLink
STATE iD NUMBER 00404060079001 <br /> CONTAINER CONSTRUCTION <br /> E. C 1 01 RUBBER LINED ( 1 02 ALKYD LINING t ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f l 05 GLASS LINING <br /> ( ) 97 UNLINED (X) 08 UNKNOWN ( 1 09 OTHER: <br /> 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING C ) 03 CATHODIC PROTECTION tX) 04 UNKNOWN ( ) 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( l 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH t ) 03 GRAVITY <br /> (CHECK APPRDPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTICN t ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE t 1 02 CONCRETE--LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( J 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> 1 O1 VISUAL (�(1 Q2 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ) 07 PRESSURE TEST 0) 09 NONE S 1 19 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REgUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 ( 1 02 ( 1 93 <br /> ( J01 1102 ( 1 0311111111111 <br /> ( ) 91 c 1 02 ( ) 03 <br /> ( ) 01 t ) 02 S ) 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> ( 1 01 ( D 02 ( ) 03 <br /> 1 01 [ 1 02 ( 1 03 <br /> ( ) 01 ( l 02 ( ) 03 <br /> E ) 01 ( 1 02 ( 1 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 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 INC (SIGNATURE) PHONE W/AREA CODE <br /> '7 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIN STRAT:� AGENCY CITY C E COUNTY CODE <br /> CONT T PERSON PH E W/AA"A C <br /> ODElL <br /> DATE OF LAST INSFECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTICN DATE LOCAL PERMIT ID # <br /> ( 1 Ol YES t ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />