Laserfiche WebLink
STATE ID NUMBER 00000018096004 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 C3 EPDXY LINING f ) 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> ( 1 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP f 7 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN f ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH f 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE f ) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: ( > 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 105 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> f ) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> f ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST (X) 09 NONE ( 1 10 OTHER.- <br /> VIII <br /> THER: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 PEEVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> ( ) O1 ( ) 02 ( 1 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( 1 03 <br /> f ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ! 3 02 ( 1 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( l Ol f 1 02 ( ) 03 <br /> ( ) Ol f l 02 f ) 03 <br /> ( J <br /> 01 ( 1 02 f ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM M�ps BEEN CO PLETEO UNDE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. <br /> Pte. <br /> ON LING (S- TURE PHO E W//AR A CODE <br /> FOR LOCAL AGENCY USE ONL <br /> ADMINISTRATING AGENCY TAPPROVALTDATE <br /> COUNTY CODE <br /> CONTACT PERSON W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMITRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( ] 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> i � <br />