Laserfiche WebLink
STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> 01 RUBBER LINED ( ) 02 ALKYD LINING 1 l 03 EPDXY LINING ( l 04 PHENOLIC LINING 1 ) 05 GLASS LINING <br /> ( l 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION 1(X1 04 UNKNOWN ( ) 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION (X) 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( '1 04 PRESSURE f 1 05 SUCTION (X) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL ( ) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST O( 1 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASP (IP KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 1 1 01 1x1 02 ( 1 03 Regular Gasoline <br /> 01 ( 1 02 ( ) 03 <br /> ( , 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 1103 I I I <br /> ( ' 01 ' ' 02 ' ) 03 I I LLLLI i I I I I I <br /> O01 f ).02 1103 IIIIIIIIiII <br /> I l 01 ( 1 02 O 03 I I I <br /> ( ) <br /> 01 ( 1 02 ( ) 03 1 1 <br /> I ) 01 ( 102 ( 1031111' III111111 <br /> 1 1 01 O 02 11 03 1 1 1 1 <br /> IS CONTAINER_LOCATED ON AN AGRICULTURAL FARM?_ ! l 01 YES IX) 02 NO <br /> 141S FORK HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS /T/RUE AND CORRECT. <br /> IPEPSON PILING (SIGNATURE) II� PHONE W/A R11�0 �o <br /> IFOR LOCAL AGENCY USE ONLY / <br />�A0 MIN STPATIN EN Y ��'/7DATE <br /> E COUNTY CODE <br /> r %A/ Ldcl ( l <br /> CONTACT PERSON NE W/ARG CODE <br /> 7.�i . <br /> DATE OP LAST INSPECTION IN COMPLIANCE PERMIT APPROVATRANSACTION DATE LOCAL PERMIT ID f <br /> ( ) 01 YES ( 1 02 NO <br /> HSC04-070185 <br /> PAGE 2 <br /> f <br />