Laserfiche WebLink
STATE ID NUMBER 00000012661003 <br />CONTAINER CONSTRUCTION <br />01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING f 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP [ 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br />[ ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br />VI PIPING <br />(. ABOVEGROUND PIPING- ( <br />l 01 DOUBLE -WALLED <br />PIPE <br />( ) 02 <br />CONCRETE -LINED TRENCH ( <br />) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) <br />( ) 04 PRESSURE ( <br />) 05 <br />SUCTION <br />( ) 06 UNKNOWN ( ) 07 <br />NONE <br />3. UNDERGROUND PIPING: ( <br />) 01 DOUBLE -WALLED <br />PIPE <br />( ) 02 <br />CONCRETE -LINED TRENCH ( <br />) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) <br />(X) 04 PRESSURE ( <br />) 05 <br />SUCTION <br />( ) 06 UNKNOWN ( ) 07 <br />NONE <br />VII LEAK DETECTION <br />eX--i"01 VISUAL (X) 02 STOCK INVENTORY [ l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />r') 06 GROUND WATER MONITORING WELLS f 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED 'i ES TO IV -F YOU APE NOT REOUIPED TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STOP -D <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( 1 01 <br />( ) 02 <br />( ) 03 <br />{ ) 01 <br />( ) 02 <br />( ) 03 _ <br />( ) 01 <br />C ) 02 <br />( ) 03 1 <br />( ) 01 <br />( J 02 <br />( ) 03 <br />f ) 01 <br />( ) 02 <br />( ) 03 <br />i ) 01 <br />( ) 02 <br />( ) 03 <br />001 <br />002 <br />0031111111111111 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />()01 <br />(1 02 <br />(1131i111141111�1 -_ <br />* CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />CS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 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 />FERSO FILING (SIGNATURE? JPHONE W/AREA CODE <br />4 - to <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTP,ATING ACI NCY <br />CITY CODE <br />COUNTY CODE <br />CONTACTP ON PHON W/A EA CODE <br />DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ZD lr <br />( ) 01 YES ( l 02 NO <br />HSC04-070185 (10/18/85) <br />0 0 <br />PAGE 2 <br />