Laserfiche WebLink
• STATE ID NUMBER <br />CONTAINER CONSTRUCTION <br />E. ( )0 RUBBER LINED ( ) 42 -ALK -YO LINING l 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br />1 07 UNLINED ( ) 08 UNKNOWN ( 1 09 OTHER: _q, <br />: <br />F. ( 101 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN CO 05 NONE <br />( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br />- J <br />VI PIPING <br />[I LEAK DETECTION <br />( ) O1 VISUAL (4 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GP•OU(tD WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( l 09 NONE 00 10 OTHER: <br />_44 <br />VIII CNEMICAl 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 (00 NOT USE COMMERCIAL NAME) <br />( 101 <br />A. ABOVEGROUND PIPING: ( <br />) 01 DOUBLE -WALLED PIPE <br />( ) 02 <br />CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOXES) <br />( ) 04'PRESSURE ( ) 05 <br />SUCTION <br />( ) 06 UNKNOWN ( ) 07 NONE <br />B. UNDERGROUND PIPING: ( <br />) 01 DOUBLE -WALLED PIPE <br />( ) 02 <br />CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) <br />( ) 04 PRESSURE (X) 05 <br />SUCTION <br />( ) 06 UNKNOWN ( ) 07 NONE <br />[I LEAK DETECTION <br />( ) O1 VISUAL (4 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GP•OU(tD WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( l 09 NONE 00 10 OTHER: <br />_44 <br />VIII CNEMICAl 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 (00 NOT USE COMMERCIAL NAME) <br />( 101 <br />c )02 <br />( )03(I <br />O 01 <br />( 1 02 <br />O 03 1 1 1 1 1 1 1 I(( I( I <br />O 01 _ <br />O 02 <br />() 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 0-3�-�( I I 111_(._1_LLl <br />( ) 01 <br />( T 02 <br />( ) 033 <br />O 01 <br />O 02 <br />f) 0,3.1 I I I I I I I I I I I <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />L <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />VIS�CO�NTAINER LOCATED ON AN AGRICULTURAL FARM? t ) 01 YES (X,) 02 NO <br />S FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUF mn rnGRFrT <br />S . FI ING (S GNA* PE) PMO NE W/AREA CODE <br />lP. LOCAL AGENCY USE ONLY <br />AOMZNIS�IN AGENCY � (� CITY ODE COUNTY CODE <br />CONTACT PERS PHO E W/ARE CODE <br />DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br />( 1 01 YES ( 1 02 NO <br />HSC04-070185 PAGE 2 <br />