Laserfiche WebLink
A <br /> r - <br /> 1../ STATE ID NUMBER 00000028637002 <br /> CONTAINER CONSTRUCTION <br /> E( 3 <br /> 1 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING f ) 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> 07 UNLINED (X) 08 UNKNOWN f ) 09 OTHER: <br /> 1 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN f ) 05 NONE <br /> 7 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f 102 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN IkK 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST t& 04 PRESSURESUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (_ OP kmnw THVFNTnRY f ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> I ) 06 GROUND WATER MONITORING WELLS 06 07 iPRSSURE TEST (X) 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 /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) O1 ( ) 02 ( ) 03 <br /> 1 ) Ol ( ) 02 ( ) 03 <br /> f 101 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> I ) 01 ( ) 02 ( ) 03 <br /> f 1 01 ( ) 02 ( ) 03 <br /> f 1 01 i ) 02 ( ) 03 <br /> f ) O1 ( ) 02 ( ) 03 <br /> ( 7 <br /> 01 ( ) 02 ( ) 03 <br /> l ) 01 1 ) 02 ( ) 03 <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS 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 /> PER SO MINGON T EI PX N W/AREA CODE <br /> C) <br /> 'la <br /> FOR LOCAL AGENCY USE ONLY <br /> ADM ISTRATINQ AGENCY CITY CODE COUNTY CODE <br /> rcdc «� Low �is�i��t J <br /> COtµ�cT/pACT PEP. ON PH NE W AREA COODD3IEL <br /> e/7a_11 'e f J /� ® �7 zLl! o7c-) <br /> OA TE OF LAST 33NSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 01 YES ( ) 02 NO <br /> KSC04-070185 (10/18/85) PAGE 2 <br />