Laserfiche WebLink
9 STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED [ ) 02 ALKYD LINING 1 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> f 1 07 UNLINED [ r 08 UNKNOWN I ) 09 OTHER: <br /> F. f ) 0 POLYETHLENE WRAP ( 1 42 VINYL WRAPPING i ) 03 CATHODIC PROTECTION ( ) 04 UFIKNOWN i ) 05 NONE <br /> Ob TAR OR ASPHALT ( ) 09 OTHER <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH 1 f 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) t ) 04 PRESSURE ( ) 05 SUCTION ( ) 46 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: { } 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST { 1 04 PRESSURE (�l 05 SUCTION ( ) 06 UNKNOWN f 1 07 NONE <br /> VII LEAK DETECTION <br /> f ) 01 VISUAL ( 102 STOCK INVENTORY l 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GP.OUI40 WATER MONITORING WELLS I ) 07 PRESSURE TEST f 1 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 REOU'.RED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# IIF KNOWN) CHEMICAL 100 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> { ) <br /> 01 ( ) 02 ( 1 03 <br /> ( ) 01 1 1 02 t ) 03 1. LLLLJ <br /> 1 ) 01 ( ) 02 ( ) 03I I I I LLI I I I - -�— <br /> ( ) 01 ( 1 02 <br /> ( 1 <br /> 01 O 02 ( 1 03 <br /> , 1 01 ( ) 02 ( ) OLLI I I l I I I I I I I_ <br /> ( ) 01 ( 1 02 f ) 03 <br /> ( 1 01 ( ) 02 ( ) 43�I I I I I II III III ILI I <br /> 1 ) 01 ( 1 02 I ) 03 <br /> T 1 01 ( ) 02 ( 1 03 <br /> LSC�ATAIHER LOCATED ON AN AGRICULTURAL FARM? t 1 01 YES (/�4 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 /> PERSON ILIN (SIGN"FE) PHONE W/AREA CODE <br /> �T c/. C <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMI13ISTPATIN04GENCY CITY CODE COUNTY CODE <br /> , <br /> CONTAiC'T}PECSON PHp� CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO p <br /> f 1 <br /> 01 IES ( 1 02 NO <br /> PAGE 2 <br /> Ii5C04-077185 <br />