Laserfiche WebLink
STATE ID NUMBER 00000010811001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ] 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( 1 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING I ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( 1 05 NONE <br /> (X) 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOM ES) ( ) 04 PRESSURE (X) 05 SUCTION f l 06 UNKNOWN f 1 07 NONE <br /> VII LEAK DETECTION <br /> F( ] O1 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT <br /> 1 06 GROUNO WATER MONITORING WELLS ( 1 07 PRESSURE TEST f 1 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 /> STORED STOPED <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) .01 ( ) 02 ( ) 03 <br /> ( ) O1 ( 1 02 f ) 03 <br /> ( ) 81 f ) 02 ( 1 03 <br /> f l <br /> 01 ( 1 02 ( ) 03 <br /> t ) <br /> 01 ( 7 02 ( l 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ] 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 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 /> PERSON G (ST ATU P HONE /A C00 <br /> fj <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTP AT/NO AGENCY CITY CODE COUNTY CODE <br /> CONTAP PERSON PHOPE W/A EEA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />