Laserfiche WebLink
STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. t t 01 RUBBER L114ED t ) 02 ALKYO LINING t 103 EPDXY LINING l 1 04 PHENOLIC LINING ( P 05 GLASS LINING <br /> t ) 07 UNLINED XX) 08 UNKUOWN t 109 OTHER: <br /> F. t 101 POLYETHLENE WRAP ! f 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION XXI 04 UttKNOWN t 1 05 NONE <br /> t ! 06 TAR OR ASPHALT t P 09 OTHER: <br /> V1 PIPING <br /> A. ABOVEOPOUNO PIPING: t 1 01 DOUBLE-WALLED PIPE ! ) 02 CONCRETE-LINED TRENCH t 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) t ) 04' PRESSURE XXf 05 SUCTION t ) 06 UNKNOWN ( 1 07 NONE <br /> B. Ut10ERGROUt4D PIPING: ( t 01 DOUBLE—WALLED PIPE ! ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE 80X(ES) ( 104 PRESSURE RX) 05 SUCTION ( 106 UNKNOWN t ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL ( ) 02 STOCK INVENTORY ! 104 VAPOR SNIFF WELLSH t 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER M041TORING WELLS t 1 07 PRESSURE TEST ( ) 09 NONE UI 10 OTHER: ATNLAY TANK "TEGRITY" <br /> TESTER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> If YOU CHECktO YES TO IV'f YOU ARE NOT REQU:REO TO COMPLlTt THIS SECTION <br /> CURFENTLY PREVIOUSLY DELETE CASO IIF KNOWN) CHEMICAL 100 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> (X) of l 1 02 ! P 03 'D ETS, L W��t TANK N� L(�TGF.g NF.F.TIF.TI _) <br /> �l f 01 (X 10$ ( ) 03 IDI 1-.L]E S L �J TESTED IN 1987 _ TEST RESUI T-a N T,OgED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> 01 02 <br /> ( ) <br /> 01 d 1 02 t P 03 I I I I I I <br /> c ) 01 t ) 02 ( 103 <br /> t 1 01 ( ) 02 ( P 0 <br /> 3 <br /> ... ._ � ! 11J.11��_._�.. ... ...- ^_ <br /> t f01 t ) 02 ( ) 03 <br /> 02 ( > 4311ll_L_i._1_L-l.I1_1_1 __ ........... <br /> ! P <br /> 0I 1 1 02 ( ) 03 <br /> IS CO'dTAINER LOCATED ON AN AGRICULTURAL FARM? l ) 01 YES (X) 02 NO e _ <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANDS TO THE BEST OF MY KNOWLEOSEe IS TRUE AND CORRECT. <br /> PERgO'+ FIL:NC tSIONATUPE 1 --__` `- .-.._�_-...••••.^.'• .^ PHONE w/AREA 0001 <br /> (909) 982-327 9 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMI:+ISTPATIN:. AGENCY s CITY CODE COUNTY CODE <br /> CONTACT P:RSON PHONE w/ARQA CODE <br /> OATt OP LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL OATS TRANSACTION DATE tCCA4 PERMIT IO 4 <br /> ( 1 01 YES t ) CI NO <br /> NSC04.070185 PAGE 2 <br />