Laserfiche WebLink
y <br /> �V STATE ID NUMBER 00000020379005 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING f l 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN f ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ] 04 UNKNOWN ( ) 05 NONE <br /> (X) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) f ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING( ( ) O1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH )_03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) t)Kd 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN f l 07 NE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL ( ) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS f ] 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE 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 CASO (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 1 1 01 ( ) 02 ( ) 03 <br /> l ) 01 ( ) 02 ( ) 03 <br /> ( 1 O1 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ] 01 ( ) 02 ( 1 03 <br /> ( 1 <br /> al ( ) 02 ( ) 03 <br /> l ) Ol ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 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 N COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILI f / PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY V <br /> ADMINISTRATING A ENCY CITY CODE COUNTY COME <br /> tAt <br /> CONTACT PERSON PH E W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID i <br /> ( ) O1 VES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> �/ \/ <br />