Laserfiche WebLink
STATE ID NUMBER 00000045121002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED [ ) 02 ALKYD LINING f ) 03 EPDXY LINING ( } 04 PHENOLIC LINING t ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN f ) 09 OTHER: <br /> F. ( ) O1 POLYETHLLERNEE WR ALT ((})02 VOTHERWRAPPING i ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> } 06 TAR <br /> VI PIPING <br /> FASOVEG:ROUNDAPPROPRIATE BOXfES) ( ( t�1040PRESSURELE[, 1I 05 SUCTION PE 02 C(X) 06EUNKNOWNTR(N)H07iNONE3GRAVITY <br /> GROUNp PIPING; ( ) O1 OpUBLE-WALLED PIPE ( } Q2 CONCRETE-LINED TRENCH ( } E GRAVITYG APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( } 07 NONE <br /> VII LEAK DETECTION <br /> (X[ 01 VIGROUNDIWATER MONITORINGNWELLS (i))007VPRESSURE APOR FTEST <br /> LLS )(09 NONE <br /> 05 ENSOR INSTRUMENT OHER: <br /> VIII CHEMICAL COMPOSITION OF RNA=REDRALS To cDMPe70RED E THIS seNIoNDERGROUNi} CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NO <br /> CN€MICAL (DO NOT USE COMMERCIAL NAME ) <br /> CU'PENTLY PREVIOUSLY DELETE CASO (IF KNOWN) i <br /> STOPED STORED <br /> ( } OI ( } 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 t } Q3 <br /> ( 1 01 t ) 02 4 ) 03 <br /> t } 01 ( } 02 ( } 03 <br /> { } 01 f } 02 ( ) 03 <br /> [ ) 01 ( ) 02 ( ) 03 <br /> ( } 01 ( ) 02 ( ) 03 <br /> [ ) 01 ( ) 02 ( ) 03 <br /> { } 01 ( ) 02 ( l 03 <br /> { } 01 f ) 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> EJS:CO�NTA��INER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> D. TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY Of PERJURY AN <br /> PHONE W/AREA CODE <br /> p!pSON FILING (SIGNATURE) <br /> FOR LOCAL AGENCY USE ONLY GGUNTY CODE <br /> CITY coo€ <br /> rCCON7ACT <br /> RATING AGENCY <br /> PHONE W/AREA CODE <br /> PERSONLAST INSPECTION JIN COMPLIANC€ P€RM17 APPROVAL DATE TRANSACTION DATE <br /> LOCAL ?ERMIT ID # <br /> ( ) Qi YES ( ) 02 NO <br /> PAGE 2 <br /> H K04-070185 (10/18/85) <br /> � i <br />