Laserfiche WebLink
STATE ID NUMBER 00000019129002 <br /> CONTAINER CONSTRUCTION <br /> E ( 1I X)ol RUBBER LINED( 1 08 UNKNOWN LINING <br /> OTHER' 05 EPDXY LINING f ) 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> 07 <br /> NED <br /> F ( 1YE <br /> (01 06LTARHORNASPHALT f(1102 VINYL WWRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> VI PIPING <br /> 01LED PIPE 02 <br /> CONCRETE-LINED TRENCH f3 GRAVITY <br /> A ABOVEGROUND <br /> CHECK IPING- N WN07NONE <br /> APPROPRIATE BOX(ES) 04 PRESSURE05 SUCTION <br /> B. UNDERGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (X) 05 SUCTION f ) Ob UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION 05 <br /> iTRUMENT <br /> �1 O1 6VSUAL IGROUND WA ER MONITORINGHWELLS t(hY 07) 04VPRESSUREFTESTLLS 1(09 NONEENSOR 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 <br /> PREVIOUSLY DELETE jCAStt (IFKNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED <br /> t ) 02 ( 1 03( ) 02 03( ) 02 ( 1 03 <br /> ( ) <br /> 01 f 1 02 ( 1 03 <br /> f 1 01 ( ) 02 t ) 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> f 1 O1 ( ) 02 ( 7 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> l 1 <br /> 01 ( 1 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) O1 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> .PHONE W/AREA CODE <br /> PERSON LING (S GNATURE <br /> FOR L CAL AGENCY USE ONLY / v <br /> CITY CODE COUNTY CODE <br /> AOMINISTRAT II AGENCY_ <br /> d <br /> IA PHONE W/AREA CODE <br /> CONT,BG.T PERSON 20 <br /> - <br /> 4 <br /> JLOCAL PERMIT I0 # <br /> DATE OF LA INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTSOH DATE <br /> ( ) <br /> 01 YES f ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br /> M • <br /> • <br />