BILLING - Laserfiche WebLink

Home Browse Search

STATE 10 NUMBER CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYO LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING t 1 05 GLASS LINING ( l 07 UNLINED QjY 08 UNKNOWN ( 1 09 OTHER: F. ( ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( W-04 UNKNOWN 1 ] 05 NONE ( ) 06 TAR OR ASPHALT f 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( l 04 PRESSURE ( 1 OS SUCTION ( 1 06 UNKNOWN 0Q 07 NONE B. UNDERGROUND PIPING: ( 101 DOUBLE-WALLED PIPE f l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) 1 'l 04 PRESSURE J6;dLO5 SUCTION ( 1 06 UNKNOWN tf 07 NONE VII LEAK DETECTION l ) 01 VISUAL 602 STOCK INVENTORY ( / 04 VAPOR SNIFF WELLS 1 ) 05 SENSOR INSTRUMENT 1 1 06 GROUND WATER MONITORING WELLS 12f 07 PRESSURE TEST ( ) 09 NONE ( l 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 PREVIOUSLY DELETE CASH (IF KNOWN) CHEMICAL 100 NOT USE COMMERCIAL NAME) STORED STORED ` ' 01 ' ) 02 ( ) 03 11 I I I I I I I I I I ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 OOl ( 1 02 ( 103lIlIIl1111111 _ 01 ` ) 02 03 LLLLLLI i I I I I I O 01 f ) 02 1 1 03 I I I I 1 1 1 1 I 1 I 1 1 1 1 Ol O 02 ( 1 n-J I II I I I I I I I I I ( 101 ( ) 02 ( 103IIIIIIi111I11 1 1 01 t 1 02 f ) 03 1 1 01 f ) 02 f 1 03 1 1 1 1 1 1 1 1 1 IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (.�"2 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE( IS TRUE AND CORRECT. PERSON ILIA 1 ONATUREI e Q` Tlj�f4CY PHONE W/AREA CODE IIIA FOR LOCAL AGENCY USE ONLY <SMCIN_IS'T_R`1NG AOC NC pco- ' , 1 D 5 , CITY CODE COUNTY_COOC CONTAC PEPSON i PHONE W/AREA CODE o20�j- 3 V_ss DATE OF LAST INSPECTION IN COMPLIA NCC PERMIT APPROVAL DATE TRANSACTION DATE IOCAI PERMIT ID S HSC04-070185PAGE 2