Laserfiche WebLink
STATE ID NUMBER 00000012403002 <br />CONTAINER CONSTRUCTION <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br />(X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION f l 04 UNKNOWN (X) 05 NONE <br />( ) 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 ( ) 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) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />(�+ 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( l 09 NONE ( ) 10 OTHER: <br />VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br />IF YCU CHECKED YES TO IV -F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STOPED <br />DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br />( ) 01 <br />( l 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />t 1 01 <br />( ) 02 <br />( ) 03 <br />f ) 01 <br />( ) 02 <br />( ) 03 <br />t ) 0.1 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( 1 01 <br />( 1 02 <br />( 1 03 <br />( ) 01 <br />( ) 02 <br />( l 03 <br />( ) 01 <br />( ) 02 <br />( ) 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 W/AREA CODE <br />4115 Z 0 S <br />IR LOCAL AGENCY USE ONLY <br />ADMINISTRATING ^ENCY !! CITY CODE COUNTY CODE <br />ma <br />l 7 C <br />CONTACT PERSON PHO E W/AREA CODE <br />DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br />( ) 01 YES ( ) 02 NO <br />HSC04-070185 (10/18/85) PAGE 2 <br />