Laserfiche WebLink
%Noe %00 STATE I0 NUMBER 00000035716001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) f ) 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) E 104 PRESSURE (X) 05 SUCTION ( l 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> fX) O1 VISUAL ( 7 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> [ ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST f 1 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 (DO NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> l l Ol ( 7 02 ( ) 03 <br /> ( I <br /> 01 f ) 02 ( ) 03 <br /> ( ) <br /> 01 ( l 02 ( ) 03 <br /> ( ) 01 f 1 02 ( ) 03 <br /> ( 7 01 ( 1 02 ( ) 03 <br /> f ) <br /> al ( l 02 ( ) 03 <br /> ( ! 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( l 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( l 03 <br /> f 1 <br /> 01 f ) 02 f 1 03 <br /> ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> Iii CEN14fCiNW L&Afff Ot9 Ah N:Fi ilcifif WA-rLfAim?P F(R HV YES 1,X) 02 No <br /> (DAYS: ..Ht"L/. .. '•, -`. " - '' INT-c. .'.t 9AME(LAST N4M*__FIPST) AND PHONE WIAOEA ^CCE <br /> THIS FORM HAS BEEN COMPLETED CINDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) PHONE W/AREA 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 ID R <br /> ( 1 <br /> 01 YES ( l 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />