BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE ID NUMBER 00000010994002 CONTAINER CONSTRUCTION E. ( 1 01 RUBBER LINED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING f 1 04 PHENOLIC LINING f 1 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. f 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( 1 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( 1 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( 1 03 GRAVITY (CHECK APPROPRIATE SOX(ES) ( 1 04 PRESSURE ( l 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE B. UNDERGROUND PIPING: ( 1 Ol DOUBLE -WALLED PIPE ( 1 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT ( 1 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 STORED PREVIOUSLY STOPED DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) ( ) O1 ( ) 02 ( 1 03 ( 1 01 ( 1 02 ( ) 03 ( 1 01 ( 1 02 ( l 03 ( ) 01 ( ) 02 ( 1 03 ( ) 01 ( 1 02 ( ) 03 ( ) 01 ( l 02 ( l 03 ( ) Ol ( ) 02 ( ) 03 ( 1 01 ( 1 02 ( 1 03 ( ) 01 ( ) 02 ( 1 03 ( 1 01 ( 1 02 ( 1 03 ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 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 CO' COUNTY CODE S 3 CONTACT,(E IOW\ Sch-YY,aX.e, PHONE W/ARE COD! DATE 1OF LAST INSPECTION INCOMPLIANCE PERMIT APPROVAL DATE CC TRANSACTION DATE d LOCAL PERMIT ID # ( ) O1 YES ( l 02 NO HSC04-070185 (10/18/85) `001 PAGE 2