Laserfiche WebLink
STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> 01 RUBBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING t ! 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> t ) 07 UNLINED ( ) 08 UNKNOWN t D 09 OTHER: <br /> F. t ) 01 POLYETHLENE WRAP t D 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION t l 04 UNKNOWN E 1 05 NONE <br /> t 1 06 TAR OR ASPHALT t D 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE—WALLED PIPE t ) 02 CONCRETE—LINED TRENCH t ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN t ) 07 NONE <br /> B. MIDERGROU140 PIPING: t T P1 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) tJW4 PRESSURE t ) 05 SUCTION t D 06 UNKNOWN t ) 07 NONE <br /> VII LEAK DETECTION <br /> t ) 01 VISUAL ( ) 02 STOCK INVENTORY t 1'04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> t ) 06 GROU14D WATER MONITORING WELLS ( ) 07 PRESSURE TEST t ) 09 NONE t D 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) CHEMICAL (00 NOT USE COMMERCIAL NAMED <br /> STORED STORED <br /> t 101 ( ) oz ( ) 03 � <br /> ( D <br /> 01 ( D 02 O 03 LlLL1—LI I I I I I I <br /> O01 O02 Oo3I I I I I ILL_� I I I I <br /> 01 ( D 02 ( ) 03 , f ,_j <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> t D 01 ( ) 02 ( ) 03 —1 <br /> F 3 01 O 02 O 03 I N I N 1 1 1 1 1 1 <br /> t ) <br /> 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 t ) 03 <br /> IS CO!1TAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES ) 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 /> PERSON ILI G (S; _ PHONE W/AREA CODE <br /> FO . LOCAL AGENCY USE ONLY <br /> AOMItISTPATIN AGENCY CITY ODE COUNTY CODE <br /> CONTACT P SON PHONE W/ARE COD <br /> l I <br /> a `� -� <br /> DATE OF LAST INSPECTIONIN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT I0 # <br /> c r <br /> J01 <br /> YES c t 02 NO <br /> .tiSC04-070185 PAGE 2 <br />