Laserfiche WebLink
`r 1.00 STATE ID NUMBER 00000061478001 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 103 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( l 04 UNKNOWN ( ) 05 NONE <br /> (X) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION [ ] 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> y7p <br /> ( ) <br /> 01 VISUAL 02 STOCK INVENTORY f 104 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> f ] 06 GROUND WATER MONITORING WELLS 01 07 PRESSURE TEST W) 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 REQUIRED TO COMPLETE THIS SECTION <br /> CUPRENTLY PREVIOUSLY DELETE CAS# IIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> f l <br /> 01 f l 02 ( ) 03 <br /> ( ) <br /> al ( ) 02 l ) 03 <br /> ( 1 01 ( ) 02 f ) 03 <br /> 11 Ol 11 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> 1 ) <br /> al ( ) 02 l ) 03 <br /> f I <br /> 01 ( ) 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> f 101 ( ) 02 ( ) 03 <br /> R CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS LONIAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM HAS COMPLETED UNDER TH OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERS N F S NATVR PNO W/ REA CODE <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 IO # <br /> ( > 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />