Laserfiche WebLink
%4r ..i <br /> STATE ID NUMBER 00000054432001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( 1 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING l 1 05 GLASS LINING <br /> ( ) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f ) 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION f 1 04 UNKNOWN l 1 05 NONE <br /> (X) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION f l 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL ( ) 02 STOCK INVENTORY [ l 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST (X) 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 CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( I <br /> 01 ( ) 02 f ) 03 <br /> t 1 01 ( ) 02 ( 1 03 <br /> ( 101 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> f 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( l O1 ( ) 02 ( ) 03 <br /> l ) 01 ( ) 02 ( 103 <br /> ( ) <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 R T PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PlPSCN FSLING (SIGNATURE) PHONE W/AREA DE� ' <br /> FOR LOCAL AGENCY USE OaY <br /> 40MINISTPATING AO!NCY CITY CODE COUNTY CODE <br /> CONT T PERSON 0 PHONE W/AREA <br /> DATE OF MT INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 0 <br /> ( ) <br /> 01 YES ( ) 02 NO <br /> NSC04-070185 (10/18/85) PAGE 2 <br /> V <br />