Laserfiche WebLink
CONTAINER CONSTRUCTION STATE ID NUMBER 00000021906001 <br /> EIGRUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING C ) 04 PHENOLIC LINING C ) 05 GLASS LINING <br /> 07 UNLINED ( ) 08 UNKNOWN ( 1 09 OTHER:OLYETHLENE WRAF ( ) 02 VINYL WRAPPING ( 1 Q3 CATHODIC PR07ECTIQN6 TAR OR ASPHALT [ 1 09 OTHER: ( 1 05 NONE <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: { 1 O1 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( J 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE { ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: { ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( J 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) { ) 04 PRESSURE ( 05 SUCTION E ) 06 UNKNOWN [ ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL {X1 02 STOCK INVENTORY [ ] 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( i 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> :F YCU CH_CKEO YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURPENTLY PPEVIOUSLY DELETE C4S# (IF KNOWN) ~- <br /> STOPED STORED CHEMICAL (DD NOT USE COMMERCIAL NAME ) <br /> r 1 01 ( ) 02 ( ) 03 <br /> ( 1 O1 f ) 02 ( 1 03 <br /> ( ) 01 C ) 02 ( ) 03 <br /> ( ) 01 ( J 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> { 1 01 i ) 02 ( ) 03 <br /> ( 1 <br /> 01 C ) 02 ( ) 03 <br /> 01 ( ) 02 ( ) 03 - <br /> ( 1 O1 r ) <br /> 02 { 1 03 <br /> ( 1 01 ( J 02 C ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? [ ) 01 YES {XI 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 /> - <br /> PERSON FILING (SIGNATURE) f J -- <br /> PHONE W/AREA CODE <br /> FOR LOCAL. AGENCY USE ONLY t <br /> ADM:NiSTRATING A ENC CITY CODE <br /> couNrY eonE <br /> CONTACT PE ON <br /> PHONE WlAREA COD <br /> DATE OF LAST INSPETION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE r <br /> 2 � ) 01 YES i ) 02 NO LOCAL PERM-T ID # <br /> HSC04-070185 E10/18/85) <br /> PAGE 2 <br />