BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE ID NUMBER 00000032222002 CONTAINER CONSTRUCTION E. ( ) O1 RUBBER LINED ( ) 02 ALKYO LINING ( ) 03 EPDXY LINING f ) 04 PHENOLIC LINING ( 1 OS GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. [ l 01 POLYETHLENE WRAP ( 7 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION CX) 04 UNKNOWN ( 7 05 NONE ( ) 06 TAR OR ASPHALT f 1 09 OTHER'- VI PIPING FA. ABOVEG!ROUND HECKOPRIATE.BOX ES) ( ( 011040PRESSURELEO )IPE 02 05 SUCTION LON)R 06EUNKNOWN ( 1H 07(NONE3GRAVITY DERGD PIPING• ( ) O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY HECKROPRIATE BOX(ES7 [ ) 04 PRESSURE ( l 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( 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 APE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CASE (IF KNOWN) CHEMICAL IDO NOT USE COMMERCIAL NAME) STORED STOPED (X) 01 ( l 02 l 1 03 16171613101 1 1 1 1 1 1 • ISOPROPYL ALCOHOL (2-PROPANOL) ( ) 01 ( ) 02 [ ) 03 l ) al ( l 02 ( ) 03 ( ) 01 ( 1 02 ( ) 03 ( ) 01 f 1 02 ( ) 03 ( 7 Ol ( 7 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 [ 1 Ol ( ) 02 f ) 03 ( ) Ol ( l 02 f 7 03 - ( ) 01 ( ) 02 f ) 03 • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f 7 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.IAREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # 1 ) 01 YES ( ) 02 NO MSC04-070165 (10/18/85) PAGE 2