Laserfiche WebLink
STATE ID NUMBER 00000001798001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUeBER LINED ( 1 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING t ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN t ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( D 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN t ] 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( D 04 PRESSURE t ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( D 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ] 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST t ) 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YCJ CHECKED YES TO IV-F YOU APE NCT PEQUIRED TO COMPLETE THIS SECTION <br /> v'PENTLY FFE7IC'JSLY DELETE CAStt (IF KNOWN) CHEMICAL (DO NOT USE CCMMEPCIAL NAME ) <br /> STOPED STCPED <br /> tD01 ( 102 ( ) 031111111111111 <br /> ( D 01 ( 1 02 O 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> t ) 01 O02 O03IIIIillllllll <br /> ( ' 01 ( ' 02 ( ' 031 I I I I I I I I I I L <br /> ( ) 01 ( ) 02 ( ) 03 <br /> t D01 ( ' 02 ( ' 031111111111111 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 f ) 02 ( ) 03 <br /> ( ] 01 ( 102 0031111111111111 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 I 1 ( I I I I I 1 <br /> # CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 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 /> (F:PSC4 FIlI43-(SI3NATURE) APEA CCDE ---� <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE <br /> COUNTY" CCCE <br /> CCNTACT FEFSCN PHONE W%APEA CCDE <br /> DATE CF LAST :NS?ECTION iN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID x <br /> t ) <br /> 01 S E S 1 ) 02 NO <br /> —�-------�— <br /> HSC04-070185 (10/18/85) PAGE 2 <br />