Laserfiche WebLink
Am <br /> STATE ID NUMBER 00000065248001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING t l 03 EPDXY LINING ( ) 04 PHENOLIC LININ t ) 05 GLASS LINING <br /> ( ) 07 UNLINED ( ) 08 UNKNOWN (X1 09 OTHER: RESIN EPDXY <br /> F. ( ) 01 POLYETHLENE WRAP t ) 02 VINYL WRAPPING, t ) 03 CATHODIC PROTECTION- t ) 04 UNKNOWN (X) 05.NONE , <br /> ( ) 06 TAR OR ASPHALT t ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOM ES) M 04 PRESSURE ( B 05 SUCTION ( ) 06 UNKNOWNt ) 07 NONE <br /> VII LEAK DETECTION <br /> t ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS (X) 05 SENSOR INSTRUMENT <br /> (X) 06 GROUND WATER MONITORING WELLS A ) 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 PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> t l <br /> 01 t ) 02 ( ) 03 <br /> O 01 t ) 02 O 03 <br /> t l 01 t ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( D 03 <br /> t ) <br /> 01 t ) 02 t ) 03 <br /> ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTIN FOR POSSIBLE SYNONYMS <br /> IS CONTAIN ERLOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON F N GNATURE) PHON W/AREA CODE <br /> . � ' <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMIN STRATYNG� GEN CYTY CODE COUNTY CODE <br /> Jpf <br /> CONTA PE SON PHONE W/AREA CODE <br /> DATE. OF�LAST INSPECTION JIN COMPLIANCE FRMAPPROVAL DATE TRANSACTION DATE LOCAL PERMIT I0 (( <br /> ((6((// ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (05/05/86) PAGE 2 <br />