Laserfiche WebLink
4 0 <br /> STATE ID NUMBER 00000063414001 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( 1 02 ALKYD LINING ( ) 03 EPDXY LINING t ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> tX) 07 UNLINED t ) 08 UNKNOWN ( 1 09 OTHER: <br /> F. t ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER*. <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: C 1 01 DOUBLE-WALLED PIPE C ) 02 CONCRETE-LIN€D TRENCH C 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION t 1 06 UNKNOWN t ) 07 NONE <br /> B. UNDERGROUND PIPING: ( } 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE 4Xv-)'05 SUCTION ( 106 UNKNOWN 4 ) 07 NONE <br /> VII LEAK DETECTION <br /> C 1 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS [ ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( 1 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 RE9UIP.ED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STC?ED STORED <br /> t f <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 t ) 02 t ) 03 <br /> ( 1 <br /> 01 ( ) 02 C ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 t ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> { 3 01 ( 102 ( l 03 <br /> t 3 01 i ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> 15 CONTAINER. LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM HAS BE N COMPLETED UNDERTHE, fENALTY,OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PE SON FIL N^ S GN P NE W/A A COD <br /> FAJOT)l y l <br /> FOR LOC L AGENCY USE ONLY <br /> ADMINISTPATIN- AGENCY CITY CODE COUNTY CODE <br /> ��v 404,17111T, cb_/15�61T 1 1 <br /> CONTA PERSON PHONE /ARE CODE <br /> w WARz& ' - a <br /> DATE OF LAST INSPECTION INCOMPLIANCE JPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( 1 01 YES [ 3 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />