BILLING - Laserfiche WebLink

Home Browse Search

• STATE ID NUMBER 00000014023003 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING f 1 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ] 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT f ) 09 OTHER- VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION (X) O1 VISUAL ( 1 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT f ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( 1 09 NONE [ l 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 STORED ( ) 01 ( 1 02 ( 1 03 ( 1 01 ( } 02 ( ) 03 ( ) 01 f ) 02 ( ) 03 f l 01 ( ) 02 ( ) 03 ( ) Ol ( 1 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 f 1 01 ( ) 02 ( ) 03 ( 1 01 ( 1 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ( ) O1 f ) 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 (SIGNA dPE) PHONE W/AREA COD f' FOR LOCAL AGENCY USE ONLY Z ADMINISTRATING AGENCY Y//S 7 CITY CODE COUNTY CODE ,5w/6 ,✓V / '4ec7� CONTACT PERSON PHONE W/AREA CODE Z09-3 X ff-570 DATE O 1=5% INS=E T N IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ZD # / 2 (/X ( ) O1 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2