Laserfiche WebLink
c <br />v <br />G7 <br />CONTAINER CONSTRUCTION <br />STATE ID NUMBER <br />t ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING t ) 04 PHENOLIC LINING t ) 05 GLASS LINING <br />( 107 UNLINED ( 1 08 UNKNOWN ( ) 09 OTHER: <br />t 1 01 POLYETHLENE WRAP ( D 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 Ut1KNOWN t ) 05 NONE <br />( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />. ABOVEGROUND PIPING: ( D 01 DOUBLE—WALLED PIPE ( 1 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN d ) 07 NONE <br />UND ERGROU)1D PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH d ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION t 1 06 UNKNOWN ( ) 07 HONE <br />VII LEAK DETECTION <br />t ) 01 VISUAL ( D 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS' ( ) 05 SENSOR INSTRUMENT <br />( 1 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST t 1 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 REQU:REO TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (If KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />( <br />)01 <br />( )02 <br />( )03(I I I I I I I I I I I I <br />(D01 <br />()02 <br />('031111111111111 <br />O01 <br />( )02 <br />( )03I I I 1 1 I H_l I I I I <br />O 01 <br />O 02 <br />O 03 <br />O01 <br />O02 <br />O03 111111111111 -- <br />" <br />01 <br />O 02 <br />( ) 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br />( <br />, 01 <br />( , 02 <br />( ) Q3_ j i <br />O01 <br />( )02 <br />( )0zl <br />( <br />1 01 <br />( ) 02 <br />( ) 03 <br />t)01 <br />(1 02 <br />0031111111111111 <br />Fis CO'ITAINER LOCATED ON AN AGRICULTURAL FARM? t D 01 YES t D 02 NO <br />THIS FORM HAS BEEN COMPLETED PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br />PERSON RILING (SIGNATURE) PHONE W/AREA COLE 14,15` 7(7� <br />FOR LOCAL AGENCY USE ONLY <br />AOMINISTRATINO AGENCY CITY CODE COUNTY CODE <br />OCONTACT PERSON <br />PHONE W/AREA CODE <br />(DATE OF LAST INSPECTION PIN COMPLIANCE( 1 O! NO (PERMIT APPROVAL DATE (TRANSACTION DATE iLOCAL PERMIT IO # <br />HSC04-070185 <br />PAGE 2 <br />