BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

CONTAINER CONSTRUCTION STATE ID NUMBER 00000011940001 E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) O1 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE ( ) 06 TAP, OR ASPHALT ( ) 09 OTHER: VI PIPING LAA6OVCEGPOUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE UNDERGROUND PIPING: ( ) O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY (CHEK APPROPRIATE BOXES) ( ) 04 PRESSURE ( 5 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL lx) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST (X) 09 NONE ( l 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS iF ,YCU CHECKED YES TO IV-F YOU APE NOT PErUIPED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CA.S# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STCRED STOPED ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 I I I ( ) 01 ( l 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) O1 ( ) 02 ( l 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( l 03 ( ) 01 ( ) 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (SIGNATURE) PH NE W/AP .4 CODS FOR LOCAL AGENCY USE ONLY .ADMT STRATIN AGENCY CITY COD ��,�,.` LAC c 701 COUNTY CODE -3 Cv^NT4PERSON PHO EI/,ARE: CODE ,3 L4tLICIAL DATE CF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE( ) O1 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2