Laserfiche WebLink
0 0 <br /> STATE ID NUMBER 00000013166001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING { ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER' <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING C ) 03 CATHODIC PROTECTION (XI 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT f 3 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: [ ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH C 3 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING= [ ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN { ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS i ) 07 PRESSURE TEST ( ) 09 NONE (X) 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 /> CUFPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( 1 03 <br /> f 1 01 ( ) 02 ( 1 03 <br /> ( 3 01 ( ) 02 t ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> { 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ] 02 ( 1 03 <br /> ( 1 01 t ) 02 ( ) 03 <br /> ( 1 01 { ) 02 { ) 03 <br /> ( ) 01 ( 1 02 ( t 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CCNTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) Cl 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 /> PERSO IL (SIGN A U E3 PHONE W/APEA CODE <br /> r 2 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRAT:NG AGENCY CITY CODE -Fu. <br /> OUNTY CODE <br /> S.9-� A t� rig ( Lv C,e4 G <br /> CONTACT PERSON \ PHONE W/AREA CODE <br /> Kf'V�t t-+ 4�►-. �-�-sa C /1 `Z o -_ <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ry -9,6 f ) 01 YES [ ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> • <br />