Laserfiche WebLink
6 STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 01 RUBBER LINED ( ) 02 ALKYD LINING 03 EPDXY LINING 04 PHENOLIC LINING 05 GLASS LINING <br /> ) 07 UNLINED (e 08 UNKNOWN ( ) 09 OTHER: <br /> F. 01 POLYETHLENE WRAP 02 VINYL WRAPPING 03 CATHODIC PROTECTION 04 UNKNOWN 05 NONE <br /> 06 TAR OR ASPHALT 09 OTHER. <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 01 DOUBLET-WALLED PIPE 02 CONCRETE-LINED TRENCH 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 04 PRESSURE 05 SUCTION (Al 06 UNKNOWN t D 07 NONE <br /> B. UNDERGROUND PIPING: 01 DOUBLE-WALLED PIPE 02 CONCRETE-LINED TRENCH 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 04 PRESSURE 05 SUCTION 0%l 06 UNKNOWN 07 NONE <br /> VII LEAK DETECTION <br /> 01 VISUAL 02 STOCK INVENTORY 04 VAPOR SNIFF WELLS 05 SENSOR INSTRUMENT--4,, <br /> 06 GROUND WATER MONITORING WELLS 07 PRESSURE TEST (>d 09 NONE 10 OTHER-- <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS .- <br /> IF <br /> ONTAINERSIF YOU CHECKED YES TO IV-F YOU ARE NOT REWIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASU (IF KNCWN) CHEMICAL 100 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 01 o, <br /> 01 02 ( 03 <br /> 01 02 ( 03 <br /> 01 02 ( 03 1 j <br /> 01 02 O 03 1 ILH Llill 111 <br /> O 01 02 ( 03 1 1 1 1 Ll I I I <br /> 01 02 ( ) 03 <br /> 3 01 02 ( ) 03 <br /> 01 02 ( D03IIIIlIIIlllll <br /> 01 02 ( 03111111111111 ( <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? 01 YES k-f 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 <br /> PEPSON <br /> FILING (SIGNATURE) PHONE W/APEA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> (ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON I PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCET�l APPROVAL DATE TRANSACTION DATE FOCAL PERMIT ID # <br /> 01 YES 02 NO _T <br /> HSC04-07018.5 reenovej kAlb 1,7?6 PAGE 2 <br />