Laserfiche WebLink
Of <br />. CONTAINER CONSTRUCTION STATE ID NUMBER 00000060123001 <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING f ) 04 PHENOLIC LINING t ) 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( P 09 OTHER? <br />F. ( ) 01 POLYETHLENE WRAP C 102 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( l 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) f ) 04 PRESSURE f ) 05 SUCTION f l 06 UNKNOWN ( ) 07 NONE <br />B. UNDERGROUND PIPING ( ) 01 DOUBLE -WALLED PIPE t ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOV ES-) t ) 04 PRESSURE (X} 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />I LEAK DETECTION <br />t ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />t ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 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 <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME)' <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />t )01 <br />( )02 <br />( )03 <br />t 1 01 <br />( ) 02 <br />( ).03 <br />01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />{ ) 01 <br />( ) 02 <br />( ) 03 <br />l 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( l 01 <br />( ) 02 <br />( ) 03 <br />( }. `01 <br />( ) 02 <br />( ) 03 <br />* CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t ) 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 />PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br />fl <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY CITY COD COUNTY CODE <br />CONTACT EPSON PHONE W/AREA CODE <br />DATE OF LAST INSPECTION FINCOMPANCE pEPMITAPPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br />) 41 YELIS ( J 02 NO <br />HSC04-070185 (10/18/85) <br />PACE 2 <br />