Laserfiche WebLink
v ../ <br /> STATE ID NUMBER 00000039074008 <br /> CONTAINER CONSTRUCTION <br /> E. ( ENED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> D (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( NE WRAP [ D 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION IX) 04UNKNOWN l 1 OS NONE <br /> ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING( ( ) 01 DOUBLE-MALLEO PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION 1 ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOABLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION 1 ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS 1 D 05 SENSOR INSTRUMENT <br /> l ) 06 GROUND WATER MONITORING WELLS 1 107 PRESSURE TEST l 1 09 NONE 1 ) 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 PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME/ <br /> STORED STORED <br /> f 1 <br /> 01 ( ) 02 ( ) 03 <br /> 1 ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> al ( ) 02 ( ) 03 <br /> 1 101 1 ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f 1 01 ( ) 02 ( ) 03 <br /> t 1 01 ( ) 02 ( 1 03 <br /> t 101 ( ) 02 ( ) 03 <br /> ( 1 O1 / ) 02 ( ) 03 <br /> ( l <br /> 01 1 ) 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 COMP O E PMTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> PERSON LINO (SI AT ) PHONE :/ARE COOS 9 <br /> 0 LOCAL AGENCY USE ONLY <br /> AOMINISTRAT NG AGENCY CITYJODE COUNTY CODE <br /> 3 <br /> CONTACT PERSON PHONE W/ARE CODE <br /> C_ e 1 c�he 1 e a,C (,9- 7(��8 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID tl <br /> ( 1 O1 YES ( ) 02 NO <br /> HSC04-070185 (05/05/86) PAGE 2 <br /> %w �� <br />