Laserfiche WebLink
STATE ID NUMBER 00000062251005 <br /> CONTAINER COHSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( 102 ALKYD LINING E } 03 EPDXY LINING i ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED t ) 08 UNKNOWN f ) 09 OTHER: <br /> F. ( ) 01 POLYM'LENE WRAP t d 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION t l 04 UNKNOWN ( d 05 NONE <br /> t l 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 t l 05 SUCTION t ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: £ ) 01 DOUBLE—WALLED PIPE i ). 02 CONCRETE-LINEA TRENCH GW 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE J D OS SUCTION t ) 06 UNKNOWN 07 NONE <br /> VII LEAK DETECTION <br /> E ) 01 VISUAL (X) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT <br /> d 06 GROUND WATER MONITORING WELLS W.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 APE NOT REgUIRED TO COMPLETE THIS`.SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS(: (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOREDSTORED <br /> t ) 01 ( ) :02 t } 03 <br /> ( ) 0,1 ( ) 02 i } 03 <br /> ( ) el ( ) 02 ( ) 03 <br /> i 101 ( ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 <br /> 01 ( ) 62 ( ) 03 <br /> 01 t d 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> f_3 01 E ) (d2 C ) 03 <br /> t ) 01 ( ) o? E ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING 'FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM HAS EEN COMPLETED UNDER THE PENALTY OF PERJURY ANDa TO THE BEST OF MY KNOWLEDGEs IS TRUE AND CORRECT. <br /> PERSON FT ING (SIGNATUR PHONE W/AREA CODE <br /> I <br /> FOR, LOCAL AGENCY USE ONLY <br /> ADMTNISTRATING AGENCY CITY CODE COUNTY CODE <br /> 732 <br /> CONTACT PEP,SON PHONE W/AREA CODE- <br /> .20 3 -3 <br /> DATE OF LAST INSPECTION IN COMPLIANCE ERM IT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 3 01 YES ( J 02 NO <br /> HSC04-070185 (10/a18/65) ' PATE -2 <br />