Laserfiche WebLink
STATE 10 NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 01 RUBBER LINED ( ) 02 ALKYD LINING 03 EPDXY LINING 04 PHENOLIC LINING 05 GLASS LINING <br /> 07 UNLINED (\4-08 UNKNOWN 09 OTHER: <br /> F. 01 POLYETHLENE WRAP 02 VINYL WRAPPING 03 CATHODIC PROTECTION (>(f 04 UNKNOWN 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 0Cr 07 NONE <br /> B. UNDERGROUND PIPING: 01 DOUBLE-WALLED PIPE 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 04 PRESSURE .(KS_05 SUCTION 06 UNKNOWN 07 NONE <br /> VII LEAK DETECTION <br /> 01 VISUAL 02 STOCK INVENTORY 04 VAPOR SNIFF WELLS 05 SENSOR INSTRUMENT'S' <br /> 06 GROUND WATER MONITORING WELLS 07 PRESSURE TEST (-\-Y-09 NONE 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 CASU (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 01 02 13 <br /> 01 02 03 <br /> 01 02 03 <br /> 01 ( ) 02 ) 03111111111 1111 -- <br /> ( <br /> 01 ( ) 02 03 <br /> ill-HLIII 1111 <br /> 01 O02 02 1 1 03 1 1 1 L I I I I <br /> f 01 02 ( ) 03 <br /> 01 02 O03lllllllfl <br /> 01 02 ) 03 <br /> 01 02 O03II11111111111 <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) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> [ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> SAN MOWN 10CAL HEAITH DISTRICT <br /> CONTACT PERSON PHONE 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 PAGE 2 <br />