Laserfiche WebLink
STATE ID NUMBER 00000039509001 <br />L0121019-1992 lzlmsjl"Ima flabli <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING f'l 04 PHENOLIC LINING ( J 05 GLASS LINING <br />j t ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER <br />F. ( ) 01 POLYETHLENE WRAP ( )'02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br />j ( ) 06 TAR OR ASPHALT ( J 09 ,OTHER: <br />PTPTM r - <br />A. ABOVEGROUND PIPING: t ) 01 DOUBLE -WALLED PIPE f ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(.CHECK APPROPRIATE BOX(ES) 00 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. UNDERGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />fCHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION (:) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />(X) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS (XI 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER <br />VIII CHEMICAL COMPOSITION OF MATERIALS SPORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED YES TO IV -F YOU ARE NOT REC<UIRED TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />f ) 01 <br />( ) 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />( ) 03 <br />J 01 <br />( ) 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />( ) 03 <br />t ? 01 <br />( ) 02 <br />( ) 03 <br />) 01 <br />( ) 02 <br />( J 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />) 01 <br />( ) 02 <br />()- 03 <br />t ) 01 <br />f ) 02 <br />( ) 03 <br />01 ` <br />( 1 02 <br />( ) 03 <br />* CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? C ) 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 />P L SIGNA URE) PHONE W/AREA CODE <br />Ch$J UrAl AtoOM,tf V [ICC nA9t V <br />ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br />CONTACT PERSON PHONE W/AREA CODE <br />DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATELCOAL PERMIT ID <br />( ) 01 YES t ).,02 N0 <br />HSC04-070185 (10/18/85) PAGE 2 <br />