Laserfiche WebLink
STATE ID NUMBER 00000038750006 <br /> CONTAINER CONSTRUCTION <br /> E. E ) 01 RUBBER LINED ( 1 02 ALKYD LINING ( l 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> t ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER. <br /> F. ( l 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING C 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> C ) 06 TAR OR ASPHALT ( ) 09 OTHER* <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: C ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH t l 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) t ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXCES) (X) 04 PRESSURE ( ) 05 SUCTION C 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS C ) 05 SENSOR INSTRUMENT <br /> C ) 06 GROUND WATER MONITORING WELLS i ) 07 PRESSURE TEST ( ) 09 NONE ( ) 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 NCT USE COM`)EPCIAL NAME) <br /> STORED STORED <br /> C ) 01 ( ) 02 ( ) 03 l <br /> ( ) 01 ( ) 02 C ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> i ) O1 ( ) 02 ( l 03 <br /> l 01 ( 1 02 C l 03 <br /> E 1 <br /> 01 C l 02 C l 03 <br /> E l 01 C 102 C ) 03 <br /> t ) <br /> 01 ( l 02 C ) 03 <br /> i 1 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? i 1 01 YES (X) 02 NO <br /> fHIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON, FILING (SIGNATURE) PH NE W/AREA CO <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> 4r 4 c-+, 3 <br /> CONTACT PERSON 4 PHONE�ARE) COD¢, r , <br /> C/r�. GGI!/1 �/9 <br /> DATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) O1 YES ( ) 02 NO <br /> HSC04-070185 (l0elal85l PAGE 2 <br /> i <br />