BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE ID NUMBER 00000052462002 CONTAINER CONSTRUCTION E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING (XI 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING* ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 103 GRAVITY (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN f 1 07 NONE B. UNDERGROUND PIPING: [ ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ] 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (�,4 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUN&VMER MONITORING WELLS ( ) 07 PRESSURE TEST (X1 09 NONE ( ) 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 STOPED ( 1 O1 f ) 02 ( ) 03 ( ) 01 ( 1 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ] 01 ( ) 02 ( ) 03 f ) Ol ( 1 02 ( 1 03 f ) 01 ( ) 02 ( ) 03 ( 1 01 f ) 02 ( 1 03 ( ) 01 ( ) 02 ( 1 03 ( ) 01 ( ). 02 ( ) 03 ( 1 01 ( 7 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 UND THE PE ALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (SIGNATURE) PHONE W/AR 0 E FOR LOCAL AGENCY ONLY ADMINISTRATING AGENCY J7 IST CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE dv7 GASB - 4y�- 6y��' DATE OF LAS INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # 2 �� ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2