Laserfiche WebLink
STATE IO NUMBER 00000042548003 <br /> CONTAINER CONSTRUCTION <br /> 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( l 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING i 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN l 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE SOXfES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: i 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (X1 05 SUCTION ( ) 06 UNKNOWN f 1 07 NONE <br /> VII LEAK DETECTION <br /> �001 <br /> VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> 06 GROU(db WATER MONITORING WELLS ( ) 07 PRESSURE TEST f ) 09 NONE ( 1 10 OTHER: <br /> li VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT RE4^UIPED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> [ ) 01 i ) 02 ( l 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 i l 02 1 ) 03 <br /> [ 1 01 ( 1 02 ( 1 03 <br /> ( 1 <br /> 01 i 1 02 ( l 03 <br /> [ l 01 ( 1 02 ( 1 03 <br /> ( l 01 ( ) 02 ( 1 03 <br /> ( ) 01 f ) 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> [ ) 01 [ ) 02 f 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 FILING (SIGNATURE) PHONE Wr'APEA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING .AGENCY CITY COOS COUNTY CODE <br /> CONTACT PERSON PHONE W/.APEA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE -REKNIT APPROVAL DATE TRANSACTION DATE LOC,4L REKNIT ID <br /> ( ) Ol YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />