Laserfiche WebLink
STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( 1 02 ALKYD LINING l 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> ( ) 07 UNLINED 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION t>< 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROU140 PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE l ) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( l 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY /"��W10 <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL ( 1 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( 1 06 GP,OUI(D WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( 1 09 NONE t 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> _( l 01 l ) 02 O 03 ll I I l I I I I I I I 1 <br /> O 01 O 02 O 03 I I I I I I I I I I I <br /> ! ) <br /> 01 ( 1 02 ( ) Oq <br /> O 01 O 02 O 01 <br /> ( ) 01 l 1 02 ( ) 03 L_'I II II II I II II II I I L <br /> ( ) <br /> 01 ( ) 02 ( ) O�L_IL <br /> ( ) <br /> 01 _ (_) 02 ( ) 03 <br /> O 01_ O 02 O 03 <br /> O 01 (_1 02_O 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES 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 ) _TP <br /> MONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTPATING AGENCY CITY CODE <br /> COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> ( 1 01 YES f 1 02 NO <br /> HSC04-070185 PAGE 2 <br />