Laserfiche WebLink
41 <br />STATE ID NUMBER <br />CONTAINER CONSTRUCTION <br />E. t 1 01 RUBBER LINED t D 02 ALKYD LINING "( 8 03 EPDXY LINING t 1 04 PHENOLIC LINING ( D 05 GLASS LINING <br />t)Q 07 UNLINED t 1 08 UNKNOWN t ) 09 OTHERS <br />F. t 1 OI POLYETHLENE WRAP t D 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION ( 104 UNKNOWN (iQ 05 NONE <br />t 1 06 TAR OR ASPHALT t ) 09 OTHERS <br />VI PIPING <br />A. ABOVEGROUND PIPING: t 1 01 OOUBLE-WALLED PIPE t ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) 04 04'PRESSURE ( 1 05 SUCTION t 106 UNKNOWN t ) 07 NONE <br />B. UNDERGROUND PIPING: t ) 01 DOUBLE -WALLED PIPE t ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOXES) (X 04 PRESSURE t ) 05 SUCTION (') 06 UNKNOWN t ) 07 NONE <br />VII LEAK DETECTION <br />04t01 VISUAL " 02 STOCK INVENTORY C>4 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT <br />) 06 GROUND WATER MONITORING WELLS D4 07 PRESSURE TEST ( ) 09 NONE ( 1 10 OTHERS <br />VIII CHEMICAL COMPOSITION OF 14ATERIALS STORED IN UNDERGROUND CONTAINERS <br />If YOU 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 (00 NOT USE COMMERCIAL NAME) <br />t -) 01 <br />( ) 02 _ <br />t D 03 <br />t 1 01 <br />t 1 02 <br />( ) 03 <br />t D 01 <br />( D 02 <br />( D 03 <br />( D Ol <br />t ) 02 <br />( ) 03 <br />( D01 <br />( )02 <br />('03N <br />t ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( D 02 <br />( ) 03 <br />01 <br />'_'02 <br />('03 LIIIINIiIII <br />t ) 01 <br />t D 02 <br />( ) 03 <br />t ) 01 <br />( 1 02 <br />t D 03 <br />[S CONTAINER LOCATED ON AN AGRICULTURAL FARM' ( 1 01 YES (A 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 ISIGNAATUURE) PHONE W/AREA CODE <br />S Z -f- 2 - <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY <br />CONTACT PERSON <br />DATE Of LAST INSPECTION JINCOMPLIANCE <br />( ) 01 YES ( ) O! NO <br />HSC04-070185 <br />t <br />CITY CODE <br />PHONE W/AREA CODE <br />COUNTY CODE <br />PERMIT APPROVAL DATE ITRANiACTXON DATE +LOCAL PERMIT ID 0 <br />• <br />PAGE 2 <br />m <br />