BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE ID NUMBER 00000063692004 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING l 1 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) OB UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (11: 04 UNKNOWN 1 1 05 NONE ( ) 06 TAR OR ASPHALT ( 7 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXf ESI ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES1 ( ) 04 PRESSURE [ 1 05 SUCTION (X) 06 UNKNOWN f ) 07 NONE VII LEAK DETECTION (X) 01 VISUAL ( 1 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS f 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STOPED STORED (Xl 01 ( 102 ( ) 03 16171613101 • )1 !)PROPYL ALCOHOL (2-PROPANOL) f ) 01 ( 1 02 f ) 03 ( 1 01 ( 7 02 ( ) 03 ( 1 Ol ( 1 02 ( 7 03 ( 7 Ol f ) 02 ( ) 03 [ 1 Ol ( 1 02 ( ) 03 f ) 01 f l 02 ( ) 03 f 1 01 ( l 02 ( ) 03 ( 1 al ( 1 02 ( ) 03 ( ) 01 ( 7 02 ( ) 03 +� CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANC[ PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( I 01 YES ( ) 02 NO HSC04-070185 (30/18/85) PAGE 2