Laserfiche WebLink
STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER LINED ( ) 02 ALKYD LINING l 1 03 EPDXY LINING f 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 1 1 07 UNLINED ( ) 08 UNKNOWN 1 1 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP 1 ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH 1 ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( 1 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE 1,11L-05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 O1 VISUAL r 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> f 1 06 GROUD TER MONITORING WELLS 1 1 07 PRESSURE TEST f l 09 NONE ( 1 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 100 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 ( 1 02 ( 1 03 <br /> f ) 01 l ) 02 ( 1 03 <br /> f 1 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( 1 O1 ( ) 02 1 1 63 <br /> f ) 01 ( ) 02 ( 1 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> f <br /> It 01 ( 1 02 ( 1 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES 1 02 NO <br /> THIS FORM HAS BEEN COMPLETED UDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE ANO CORRECT. <br /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE G/ <br /> FOR LOCAL AGENCY USE ONLY <br /> AOMZNISTRATI AGENCY CITY COOS COUNTY C00E <br /> CONTACT PERSON P NE W/AREA COD! <br /> a�� z <br /> DATE OF LAST INSPECTION IN COMPLIANC! PERMIT APPROVAL DATE TRANSACTION DATE IOCAI PlRMIT ID 0 <br /> f 1 <br /> 01 YES ( 1 02 NO <br /> TP <br /> PAGE 2 <br />