Laserfiche WebLink
, • STATE ID NUMBER 00000015803002 <br /> CONTAINER CONSTRUCTION <br /> E. l 1 01 RUBBER LINED l ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> l ) 07 UNLINED (X) 08 UNKNOWN ( 1 09 OTHER <br /> F. l 1 0l POLYETHLENE WRAP ( 7 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION lX) 04 UNKNOWN ( 7 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 7 09 OTHER: <br /> VI PIPING <br /> A (CHECKRAPPROPRIATE•BOX(ESI E 40 PR ESSUR ELED )I05 SUPE CTI02 ON CON 1RObEUNKNOWNLINED TRfN TRENCH <br /> GRAVITY <br /> B (NDERGROUND PIPING:RIATE BOX(ES14OUBLr <br /> PR ESSURELED )I05 SUCTION PE 02 CON IR 06EUNKNOWNTRENCH 07(NONE GRAVITY <br /> PP <br /> CK <br /> VII LEAK DETECTION <br /> 05 <br /> R INSTRUMENT <br /> r0t <br /> ) VISUAL <br /> WATER MONITORING WELLS( l ))107VAPOR PRESSUREFTESTLLS )(09 NONEEN( ) 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 CAS1i (SF KNOWN) <br /> CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 (. ) 02 ( ) 03 <br /> ( ) O1 ( 1 02 ( ) 03 <br /> l ) 01 ( ) 02 ( ) 03 <br /> ( 7 Ol ( 7 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( l 02 ( 1 03 <br /> ( l O1 ( l 02 ( ) 03 <br /> ( 1 O1 ( 7 02 [ ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> * CHECK STATE BOARD CH€MICAL 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 /> PHONE W/AREA CODE <br /> PERSON FILING fSIGNATUR <br /> FOR LOCAL AGENCY USE ONLY <br /> CITY CODE COUNTY CODE <br /> M <br /> E E <br /> PHONE W/AREA CODE <br /> COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID k) O1 YES ( ) 02 NO <br /> PAGE 2 <br /> KSC04-070185 (10/18/85) <br />