Laserfiche WebLink
CONTAINER CONSTRUCTION <br />STATE ID NUMBER <br />E. 1 1`01 RUBBER LINED ( 1 02 ALKYO LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br />07 UNLIIIEO ( 1 08 UtlyNOWN 1 I 09 OTHER: <br />F. 1 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN PXG 05 NONE <br />( 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: l 1 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( 1 03 GRAVITY <br />(CHECK APPROPRIATE BOXES) ( 1 04'PRESSURE l 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />S. uNDERGROU10 PIPING: ( 1 01 DOUBLE-WALLEO PIPE I 1 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOXIEST ( 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />1 1 01 VISUAL ()� 02 STOCK INVENTORY <br />1 ! 06 GP,OU101 WATER MONITORING WELLS <br />1 ) 04 VAPOR SNIFF WELLS 1 ) 05 SENSOR INSTRUMENT <br />( 1 07 PRESSURE TEST l 1 09 NONE (1t) 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 />CWLENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE <br />CASK (If KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />1 (1 (1 1 1 1 1 1 1 ( 1 <br />01 <br />() 02 <br />() 03 <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />O 02 <br />O 03 <br />( )O1 <br />( )02 <br />('0311 <br />l l l l l l l l l l l <br />l ) 01 <br />( 1 02 <br />( 1 03 <br />I )01 <br />(, 02 <br />11 03 <br />1 1 1 1 1 1 1 1 1 1 1 1 1 <br />(' 01 <br />" 02 <br />(' 03 <br />LI I I I I l N l l l l <br />1 l 01 <br />( ) 02 <br />1 ) 03 <br />`' 011 <br />02_' <br />' 03 <br />1 1 1 1 1 1 U V I I I <br />[11_C NTA NER LOCATED ON AN AGRICULTURAL FARM? <br />( ) 01 YES ( � 02 NO <br />THIS F.PRM HAS BEEN COMPLETED UIIDER THE PENALTY OF PERJURY ANDi TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br />`P 0`1�fInlI4GNI UiE) PHONE W/AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />•OnIljIr �A;E�:CY -4dCITY CODE IC' <br />OUNTY CODE <br />O\yf_) <br />CONTACT 0E9.SC PHO E W/AREA CODE <br />A V o o <br />DATE Of LAST INSPECTION ill- COIPL ANCE PERMIT APPROVAL DATE TRANSACTION DATE IOCAI PERMIT ID R <br />( ( 01 NES ( 02 NO <br />aSC04-07'3185, <br />PAGE 2 <br />