BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE ID NUMBER 00000008466003 CONTAINER CONSTRUCTION 01 RUBBER LINED ( ) 02 ALKYD LINING (X) 03 EPDXY LINING f ) 04 PHENOLIC LINING ( 1 05 GLASS LINING ( ) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER= F. f ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT f ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X1 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) Ol DOUBLE-MALLEO PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE f ) 05 SUCTION ( 1 06 UNKNOWN ( l 07 NONE VII LEAK DETECTION (X101 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST l ) 09 NONE 1 ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS% (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STOPED (X) 01 ( ) 02 ( ) 03 171616141913191 * SULFURIC ACID (OLEUM) (X) 01 ( ) 02 ( ) 03 171619171317121 1 1 1 1 1 NITRIC ACID 1 ) 01 ( ) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 ( 101 ( ) 02 ( ) 03 f 1 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 1 I Oi ( ) 02 ( ) 03 ( ) O). ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DAT! TRANSACTION DAT! LOCAL PERMIT IO R ( ) 01 YES ( 1 02 NO HSC04-070185 (10/18/85) PAGE 2