Laserfiche WebLink
46 <br /> STATE 10 NUMBER 00000034934001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( 7 02 ALKYD LINING ( ) 03 EPDXY LINING f ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER= <br /> F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f l 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 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 (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ] 07 NONE <br /> VII LEAK DETECTION <br /> 01 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( ) 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) <br /> STORED STOPED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> t ) 01 ( ) 02 ( ) 03 <br /> ( l <br /> 01 ( ) 02 ( ) 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> t 7 01 f ) 02 ( ) 03 <br /> f 1 01 f S 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 t ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) O1 ( ) 02 ( ) 03 <br /> ( ) 01 f 1 02 ( ) 03 <br /> ( 1 01 f ) 02 f l 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 /> PE N F LING 1 IG NATUP. ) <br /> ( �,j/6GiL PHONE W/AREA ---- <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATE AGENCY <br /> SSCA( /�� �`� CITY CODE COUNTY CODE <br /> CCNTACT PERSON [' N �t, J� <br /> FV1z I-drv_6.. k/Q wer 5u.perih`e#\c(e j PHONE W/AREA CODE <br /> ao <br /> UATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE <br /> S- ( ) 01I YES 1 ) 02 NO LOCAL PERMIT ID # <br /> �-070185 (10718785) C lO swre, <br /> PAGE 2 <br />