Laserfiche WebLink
STATE ID NUMBER 00000065391013 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING t 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (XI 07 UNLINED ( ) 08 UNKNOWN ( 1 09 OTHER= <br /> F. ( ) 01 POLYETHLENE WRAP i ) 02 VINYL WRAPPING [ ) 03 CATHODIC PROTECTION ( f 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT [ 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> ICHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) Qkt_04 PRESSURE (X1 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS (X) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER 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 RE4UIRE0 TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> (X) O1 ( ) 02 ( ) 03 115111510181 POTASSIUM CYANIDE <br /> (X) O1 ( 102 ( ) 03 1114131313191 SODIUM CYANIDE <br /> (X) 01 ( 1 02 O 03 111311101713121 SODIUM HYDROXIDE <br /> (X) 01 t ) 02 ( ) 03 15171112151 CYANIDES, INORGANIC SALTS Oki <br /> ( } 01 ( ) 02 ( ) 03 <br /> ( l <br /> 01 ( l 02 ( ) 03 <br /> ( 1 <br /> 01 t ) 02 ( 1 03 <br /> ( 1 <br /> 01 ( ) 02 ( 1 03 <br /> [ ) 01 [ 1 02 ( ) 03 <br /> t 1 O1 ( ) 02 ( 1 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 BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANDv TO THE BEST OF MY KNOWLEDGE> IS TRUE AND CORRECT. <br /> NE W/ EA CODE 4 <br /> ,1 ca�Cf <br /> FOR LOCAL AGENCY USE ONLY <br /> ,ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT aD # <br /> ( ) 01 YES t ) 02 NO <br /> HSC04-070185 (05/05/86) PAGE 2 <br />