Laserfiche WebLink
i <br /> • STATE IO NUMBER 00000036322001 <br /> CONTAINER CONSTRUCTION <br /> E(t <br /> O1 RUBBER LINED ( ) 02 ALKYD LINING f 1 03 EPDXY LINING ( l 04 PHENOLIC LINING t ) 05 GLASS LINING <br /> X1 07 UNLINED ( ) 08 UNKNOWN09 OTHERO1 POLYETHLENE WRAP f l 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION (X1 04 UNKNOWN ( ) 05 NONE <br /> ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> 02 A ABOVEGROUNDRIATE <br /> t ( 010DOUBLE-WALLED 4 PRESSURE ( PIPE <br /> I05 SUCTION CON'RE06EUNKN�WNTREN�H 07I NONE <br /> 3 GRAVITY <br /> CHECK <br /> ( 01DOUBLE-WALLEDP1CON R ETRENCH [ 3 GRAVITY <br /> B. UNDERGROUNDRGROUNDPIPING: <br /> 06 W107NONE <br /> (CHEPBOX(ES) 04 PRESSURE SUCTION 1 <br /> VII LEAK DETECTION <br /> NST <br /> UMENT <br /> fX` ) 06ISUAL GROUND(X) 02 STOCK WATER MONITORINGNTORYWELLLS [[)10 07 PRESSUREAPOR FTESTLL(S 1[ 05 09 NONEEN( ) 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 PRCVIOUSLY DELETE CASk (IF KNOWN) <br /> CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> t I <br /> 01 [ 1 02 ( ) 03 <br /> ( 1 01 ( ) 02 ` ( ) 03 <br /> rlf 1 02 ( ) 03 <br /> 1 ( ) 02 ( ) 03 <br /> 1 ( ) 02 ( ) 03 <br /> 1 t ) 02 ( ) 03 <br /> 1 f ) 02 ( ) 03 <br /> 1 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ■ 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 FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> CITY CODE <br /> ADMINISTRATING AGENCY <br /> COVNTY CODE <br /> PHONE W/ARE.A CODE <br /> CONTACT PERSON 1 . <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID k <br /> ( ) O1 YES ( ) 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />