Laserfiche WebLink
STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> . 1101 RUBBER LINED [ 1 02 ALKYD LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> f I 07 UNLINED ( 1 08 VIlK1{OW4 I 1 09 OTHER, <br /> F. I ] 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION ( 1 04 (R{KNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT [ 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGP.OUI{D PIPING- 1 1 01 OOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH [ 103 GRAVITY ~- <br /> ICHECK APPROPRIATE BOX(E51 ( 1 04 PRESSURE ( 1 05 SUCTION I ) 06 UNKNOWN ( 1 07 NONE <br /> 5. UNDERGROUND PIPING- ( 1 01 DOUDLE-WALLEO PIPE ( ) 02 CONCRETE-LIHEO TRENCH (),1 03 GRAVITY ~� <br /> (CHECK APPROPRIATE BOX(ES) I 1 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN l ) o-7`E <br /> VII LEAK DETECTION <br /> (, 1., 01 VISUALt 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUt7E8T s <br /> )-06 GRCUN_ TER N0141TORING WELLS ( 1 07 PRESSURE TEST ( ? 09 NONE ( 1 10 OTHER: <br /> VIII CIIEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU AAE NOT REQUIRED TO COMPLETE THIS SECTION <br /> .CURSENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL 100 NOT USE COMMERCIAL NAME ) <br /> STOVED STOP!O <br /> { 1 O1 i 1 02 1 03 11 I [ I <br /> { I 01 f i 02�( 1 03I ' + I U <br /> ( 1 01� ( 1 02 { 1 03 [ [ [ <br /> i t <br /> 01 f 1 02 <br /> raol -f 102 ( 10�L1 [ f11llll_L <br /> 1 1 01 f 1 02 1 1 03 LU-111 111 1111 <br /> - <br /> ( 101— ( 102 ( IO3L! IILlIf [ [ [ 1 [ <br /> {;I 01-- --f I 02 <br /> -{ 1 01 _ C T1-02 ( 1 03� <br /> , 02 - ( 1-03�_-�1—L�-L_��_.__�� <br /> IS (.C'ITAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES I j 02 NO <br /> - .._ <br /> THIS FORM HAS BEEN COMPLETED U14DER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PHONE WI AQLA CODE <br /> FOP LOCAL AGENCY USE ONLY <br /> I:D•^i ve T:!; air is—Y .. CITr COO <br /> ,lJ/ST -_ - - <br /> -5�4 �COU,:T. CODE <br /> A-ell f PnONE u/ALFA COOP: <br /> s'`f1 <br /> DATE Or LAST INSCECTION IN COMPLIANCE PERM OC <br /> i+! L DATE IIrTvAN$AC7ION OaTf LOCAL PEvnIT IO b <br /> C r � 1 q T APPA VA02 ti'O 1 <br /> -- <br /> PAGE 2 <br />