BILLING - Laserfiche WebLink

Home Browse Search

STATE ID NUMBER 00000013749001 CONTAINER CONSTRUCTION E. ( 1 01 RUBBER LINED C 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( 1 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X1 04 UNKNOWN [ 1 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(E5) t 1 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE C ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE f 1 05 SUCTION C ) 06 UNKNOWN C 1 07 NONE VII LEAK DETECTION F0�1SAL (X1 02 SOCK INVNTORY ( ) d4 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENTGROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST f ) 09 NONE ( ) 10 OTHER VIZI CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIPED TO COMPLETE THIS SECTION CUPPENTLY PREVICUSLY DELETE CASU (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STO-ED STOPED C 1 01 ( ] 02 C ) 03 ( 1 01 C ) 02 ( ) 03 ( ) 01 C ) 02 ( 1 03 f ) 01 ( 7 02 C ) 03 ( ) 01 ( ) 02 ( ) 03 ( 1 01 C ) 02 ( 1 03 ( ) 01 ( 1 02 ( 1 03 ( ) 01 ( 1 02 ( ) 03 i 7 01 ( ) 02 ( ) 03 ( l 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, 15 TRUE AND CORRECT. PEPSON ING USIGNATURf P I ( TRE 111V FOR LOCAL AGENCY USE ONLY ADMINISTRATING AQENCY CITY CODE COUNTY CODE �J G CONTACT PERSON PHONE W/AREA CODE ___[ DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO 13 ( ) 01 YES ( 1 02 NO HSC04-070185 (10/18/85) PAGE 2