Laserfiche WebLink
# r <br /> STATE ID NUMBER 00000011519003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> (X1 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN [ ] 05 NONE <br /> (X) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 107 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 REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) <br /> 01 ( ) 02 f ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> 1 ) SI ( J 02 ( ) 03 <br /> ( 1 01 ( ] 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( 1 01 f ) 02 f l 03 <br /> ( ) <br /> 01 f ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( 1 01 f 1 02 ( ) 03 <br /> O <br /> 01 ( ) 02 ( ) 03 <br /> 4E 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 F LZNG (SZ NATVRE) PHONE W/AREA CODE <br /> FOR OCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY D+S7 CITY CODE COUNTY CODE <br /> SAA/ �73? u( <br /> CONTACT PERSON PHONE W/AREA CODE <br /> A--,� <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES l 7 02 NO <br /> HSC04-070185 (0010/18/85) PAGE 2 <br />