Laserfiche WebLink
4 <br /> STATE ID NUMBER 00000061703002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 104 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED f ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( 102 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN f ] 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ] 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN Tw <br /> 7 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE =05 SUCTION ( ) Ob UNKNOWN f ] 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL (X) 02 STOCK INVENTORY l l 04 VAPOR SNIFF WELLS ( 105 SENSOR INSTRUMENT <br /> ( 106 GROUND WATER MONITORING WELLS L. <br /> %:�07 PRESSURE TEST ( ) 09 NONE ( 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> :F YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUPPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME] <br /> STORED STOPED <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> 1 01 ( ) 02 ( ) 03 <br /> ( 101 ( 102 ( ) 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> f ) 01 ( ) 02 ( 1 03 <br /> ( ) Ol f 102 ( ) 03 <br /> ( 101 f ) 02 ( ) 03 <br /> ( ) <br /> 01 ( l 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON F IN (SiONATURE) PHONE W/AREA CODE <br /> 09 �7 - 3 & H/ <br /> FOR LOCAL AGENCY USE ONLY <br /> ADC STR ATINO AGENCY CITY CODE COUNTY CODE <br /> dQ I 3 <br /> CONT6WPERSON PHONE W/AREA CODE <br /> e <br /> DATE OF LAST IN PEC/T�ION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 3 - _-Tr V 00/11 YES ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) 'f'I•`�"� <br />