BILLING - Laserfiche WebLink

Home Browse Search

STATE ID NUMBER 00000007408001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING (X1 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f l 03 CATHODIC PROTECTION ( ] 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT l ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE f ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION (X) 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 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 PPE'JIOUSLY DELETE CAS# IIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STOPED (X) 01 ( ) 02 ( ) 03 CASPHALT, LIQUID 46e5Q f ) 01 ( ) 02 f ) 03 ZB l l 01 ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 ( 1 01 f ) 02 ( ) 03 ( ) 01 f ) 02 ( ) 03 f ) Ol f ) 02 ( ) 03 ( ) 01 ( 1 02 ( ) 03 ( ) Ol ( ) 02 ( 1 03 ( 1 Ol f ) 02 ( ) 03 ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/APEA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2