Laserfiche WebLink
STATE IO NUMBER 00000013074002 <br /> CONTAINER CONSTRUCTION <br /> E) o <br /> BER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 7 05 GLASS LINING <br /> UNLINED (X) 08 UNKNOWN ( 1 09 OTHER: <br /> YETHLENE WRAP [ ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION fX) 04 UNKNOWN ( ] 05 NONE <br /> TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A (CHECKRAPPROPRIATEPIPING: <br /> BOX(ES) ( f 01 04 DOUBLE-WALLED PRESSURE <br /> 1105 SUCTION CONCRETE-LINED(( ) 06UNKNOWNTR`N;H 07 NONE <br /> 3 GRAVITY <br /> NONE <br /> B (7CHECKRAPPROPRIATEPIPING: <br /> BOXIEST f ( 01104 PRESSUREDOUBLE-WALLED X)105 SUCTION CON 1R 06EUNKNOWNTRENCH <br /> 07( 3 GRAVITY <br /> NONE <br /> VII LEAK DETECTION <br /> 05 <br /> ENT <br /> 41H' VISUAL <br /> (XI 02 STOCK <br /> WATER MONITORINGNTORYWELLS fl1I007VAPOR <br /> PRESSURESNIFF <br /> EN <br /> TEST <br /> )(09 NONE ( ) INSTR10 OTHER'- <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIPEO TO COMPLETE THIS SECTION <br /> r <br /> PP.EVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED <br /> ( 7 02 ( ) 03 <br /> ( ) 02 ( 1 03 <br /> ( ) 02 ( ) 03 <br /> ( l <br /> 01 ( ) 02 f ) 03 <br /> ( 7 <br /> 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 f ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 I ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( 7 02 ( ) 03 <br /> f ) 01 ( 1 02 [ 1 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 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 (SION.AT PHONE W/AR CO N <br /> FOR LOCAL AGENCY USE ONLY CJy <br /> AOMTNISTRATING AGENCY <br /> CITY CODE COVNTY CODE <br /> PHONE W/AREA CODE <br /> CONTACT PERSON <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT I0 # <br /> ( ) 01 YES l ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />