Laserfiche WebLink
STATE IO NUMBER 00000062064002 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 7 04 PHENOLIC LINING ( 7 05 GLASS LINING <br /> (X) 07 UNLINED ( 1 08 UNKNOWN ( 1 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( 104 UNKNOWN ( ) 05 NONE <br /> 6 ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 105 SUCTION ( ) 06 UNKNOWN f ) 07 NONE <br /> B. UNDERGROUND PIPING ( �)yO1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) y04 PRESSURE ( Y OS SUCTION f d 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> f ) 06 GROUND WATER MONITORING WELLS C�Q PRESSURE TEST ( 1 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINER'S <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE. THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) Ol- ( ) 02 ( ) 03 <br /> f ] GI ( ) 02 ( ) 03 <br /> { ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) Ol. ( ) 02 ( ) 03 <br /> ( ) Ol. ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 63 <br /> t ) Ol ( ) 02 ( 1 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 HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILINO (SIO TVRE) PH W/AREA CODE p <br /> ! ij B3B -SZ/ <br /> FOR LOCAL AGENCY USE LY <br /> ADISTPA�G AGENCY / C CITY CODE <br /> M COUNTY CODE <br /> „�itr[/E��6IV <br /> 1 �pp der/q.�L'� lit J T` /AREA/�( <br /> CONTA GT N P <br /> /�J� J✓o D���Y <br /> DATE OF LASTV' ECTION IN COMPLIANCE PERMIT APPROVAL DATE `TRANSACTION DATE LOCAL PERMIT ID # <br /> 31('74% ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (.10/18/85) PAGE 2 <br />