Laserfiche WebLink
is STATE ID NUMBER <br />CONTAINER CONSTRUCTION <br />0J1 RUBBER LINED ( ) 02 ALKYO LINING t 103 EPDXY LINING ( ) 04 PHENOLIC LINING t ) 05 GLASS LINING <br />7 UNLINED ( ) 08 Uf(KNOWN ( l 09 OTHER: <br />F. ( l 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE <br />( 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI - PIPING <br />T_ <br />IA. ABOVEGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04'PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN { ) 07 NONE <br />8. UNDERGROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND ATER 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 />1CURRENTLY <br />1 STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) O1 <br />( l 02 <br />( ) 03 <br />( l O1 <br />( ) 02 <br />( l 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />( ) 02 <br />( l 03 <br />r ( ) 01 <br />( ) 02 <br />( ) 03 <br />t l Ol <br />( ) 02 <br />( ) 03 <br />` ( ) O1 <br />( ) 02 <br />( ) 03 <br />01 <br />( l 02 <br />( ) 03 <br />I. ) 01 <br />O 02 <br />O 03 <br />T'. CONTAINER LOCATED ON AN AGRICULTURAL FARM? t ) 01 YES 02 NO <br />AWS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br />RSON FILING (SIGNATURE) PHONE W/AREA CODE <br />FOP. LOCAL AGENCY USE ONLY <br />/1DMIN2 TRATING AGENCY CITY CODE COUNTY CODE <br />(a <br />�dONTACT PEF.SON i" PHONE W/AREA CODE <br />,*ATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br />r ( ) O1 YES ( ) 02 NO <br />aC04-070185 <br />$0 <br />0 <br />PAGE 2 <br />