Laserfiche WebLink
0 STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER LINED ( ) 02 ALKYD LINING' 1 ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 105 GLASS LINING <br /> ( 1 07 UNLINED ( ) 08 UNKNOWN ( 1 09 OTHER: <br /> F. ( I 01 POLYETHLENE WRAP [ 102 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( ) 05 NONE <br /> ( 106 TAR OR ASPHALT 1 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE l ) 02 CONCRETE-LINED TRENCH 1' 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE 1 1 05 SUCTION ( 1 06 UNKNOWN ( l 07 NONE <br /> B. UNDERGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH (X1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE l 1 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> f ) <br /> 01 VISUAL 1 ) 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS X 05 SENSOR INSTRUMENT <br /> 1 ) 06 GROU110 WATER MONITORING WELLS ( 107 PRESSURE TEST ( l 09 NONE t 110 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 (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 O 02 f 1 03 I I I I I l I 1 1 1 1 1 I <br /> 1101 ( ) 02 1 103Li I I I I I I I I I I I <br /> 1 101 ( 1 02 l 103 LLLLL1_1 <br /> l 1 01 1 1 02 ( 1 03 <br /> ( ) 01 ( ) 02 1 ) 03 I I I <br /> ( 1 01 l ) 02 ( ) 03 <br /> 1 , 01 1 , 02 ( ) 031111111111111 <br /> 1 1 Ol ( 1 02 ( ) 03�L <br /> ( I <br /> 01 1 ) 02 ( 1 03 <br /> ( 1 01 1 102 l ) 03 <br /> IS MITAINER LOCATED ON AN AGRICULTURAL FARM? 1 1 01 YES 1 1 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 /> P�RSOtI �l `)�p�I fA 7UP PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTPATINO AGENCY CITY CODE COUNTY CODE <br /> N - <br /> CON-eSrr P-y�FjCON PHONNEJLI//=RC C�,ODE <br /> DATEw OF LAST INS EEITION TZN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID R <br /> � 01 YES ( I 02-NO <br /> ,ISC04-`079(185 V PAGE 2 <br />