Laserfiche WebLink
CONTAINER CONSTRUCTION STATE ID NUMBER 00000009554004 <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP l 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN <br /> ( 1 06 TAR OR ASPHALT ( 1 09 OTHER: fXl 05 NONE <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( Q3GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> {X) 01 VISUAL f 1 02 STOCK INVENTORY ( ] 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> (X) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REgUIRED TO COMPLETE THIS SECTION <br /> 1)'01 <br /> NTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> ED STORED CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> Ol ( ) 02 ( 1 03 <br /> 01 ( ) 02 f 1 03 <br /> ( ) 02 ( ) 03 <br /> f ] <br /> 01 ( ) 02 ( 1 03 <br /> mit" <br /> 02 ( 1 03 <br /> 02 ( 1 03 <br /> 02 ( 7 03 <br /> 02 ( ) 03 <br /> 02 ( ) 03 <br /> 02 ( ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PE RY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILINO� <br /> PHONE W/AREA CODE <br /> FOR LOCAL AGENCYUSE ONLY <br /> ADMINISTRATING AGENCY afS� CITY CODE <br /> S t-j � 0 f �_ N ` COUNTY CODE <br /> O Gam(- L c <br /> CONTACT PERSON <br /> will <br /> < ( n/l/ /�_ /T PHONE W/AREA CODE <br /> DATE OF LAST ILq PECTICN VINV COMPLIANCE v L-/ PERMIT APPROVAL DATE TRANSACTION DATE <br /> 7 ( ) 01 YES ) 02 NO LOCAL PERMIT ID # <br /> iSC04-070185 (10/18/85) <br /> PAGE 2 <br />