Laserfiche WebLink
STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. f 1401 RUBBER LINED ( 1 02 ALKYD LINING 1 1 01 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING, <br /> 07 UNLINED ( ) OB UNKNOWN ( ) 09 OTHERM <br /> F. 1 ) 01 POLYETHLEHE WRAP ( 1 02 VINYL WRAP! 1 1 0} CATHODIC PROTECTION ( 1 04 UNKNOWN ( 1 05 NONE <br /> 1 1 06 TAR OR ASPHALT tA 09 OTHER: <br /> VI PIPING ✓> J <br /> �A. ABOVEGROUND PIPING: 1 1 01 DOUBLE-WALLED PIPE 1 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> 1111111 (CHECK APPROPRIATE BOX(ESI l 1 04 PRESSURE l 1 05 SUCTION ( 1 06 UNKNOWN Ikl 07 NONE <br /> t6. UNDERGROUD PIPING: t>4 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> Il (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE l ) 05 SUCTION ( 1 06 UNKNOWN l 1 07 NONE <br /> YII LEAK DETECTION <br /> f1 ) 01 VISUAL 1 ) 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> E 1 1 06 GP.OUD NATER MONITORING WELLS 1 ) 07 PRESSURE TEST 1 1 09 NONE " 10 OTHER: / AL d <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 /> RENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> IX) 01 ( 1 02 O 03 <br /> ( 1 01 ( 1 02 ( 1 03 t I I I t l l <br /> I I ) 01 ( ) 02 ( 1031111111111111 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> 1101 ( ) 02 1 ) 03iltlltlltllil <br /> 1101 1102 ( 103 Itliitllilll <br /> 1101 ( ) 02 ( 1 07IIIIIIillltll _ <br /> 1 1 01 ( 1 02 O OS I t I I I I I t I I t t <br /> 1 ) 01 ( ) 02 l ) 03 I I I I I I I I I I I t t <br /> I, ( 1 01 ( 1 02 ( 1 03 I t I I I I I t t I t t <br /> L35 CO'ITAINER LOCATED ON AN AGRICULTURAL FARM? 1 1 01 YES ()-0 02 NO <br /> YWIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, I5 TRUE AND CORRECT. <br /> )EPSON FIlfNO (SIONATUiCI PHONE W/AREA CODE <br /> coq- per/- X3ro_ <br /> FOR LOCAL AGENCY USE ONLY <br /> IAO l,)fSTPATIND AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> OATS OP LAST INSPECTION (IN COMPLIAMCE (PERMIT APPROVAL DATE TRANSACTION DATE - LOCAL PERMIT IO-K <br /> ) 01 NYS ( )- 02 NO I` --- -- -- <br /> ASC04-070165 PAGE 2 <br />