Laserfiche WebLink
• 0 STATE ID NUMBER 00000014297001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTIN (X) 04 UNKNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. (CHECKRPPROPRIATEPIPING: <br /> BOX(ES) ( ( 0104 PRESSUREDOUBLE-WALLED PIPE <br /> 05 SUCTION CONCRETE-LINED( 06UNKNOWNTR(N 1H 07( ) 03 3 GRAVITY <br /> NONE <br /> B (CHECK APPROPRIATE BOX(ES) ( ( 0104 PRESSURELE(X) 05 SUCTION CONOR 06E-LINEDUNKNOWNTR(NOH07( 3 GRAVITY <br /> NONE <br /> VII LEAK DETECTION <br /> 05 <br /> ( ( 01VSUAL 02 STOCK 06IGROUN W TER MONITOR NGNWEL LS (( 11007VPRESSUREAPOR FTESTLLSX)f 09 NONE 1D 10SOTHERNT <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 /> STORED STORED <br /> ( 1 O1 ( ) 02 ( ) 03 <br /> f 1 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( 1 03 <br /> f 1 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ] 02 ( ] 03 <br /> ( ) <br /> 01 ( 1 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( 1 O1 ( l 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 PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATVRE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY 6,wQ <br /> O<s CITY CODE COUNTY CODE <br /> ADMINIST P.AT NG AGENCY 1 <br /> CONTACT PERSON PHONE W/AREACODE ��� _ <br /> /� O-IVAIIS ©RRQvcic 71 J <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> bd ( ) 01 YES ( 1 02 NO <br /> -J' <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />