COMPLIANCE INFO_1985-1999 - Laserfiche WebLink

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STATE ID NUMBER 00000001798007 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING t ) 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP t ) 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN t ) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER VI PIPING A ABOVEGROUND PIPING. { ) 01 DOUBLE—WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE' ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE { ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION (X)' 01 VISUAL ( ) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT E ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STOPED STOPED (X) 01 ( ) 02 ( ) 03 ASPHALTo PAVING GRA pE AR4000 t )' 01 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 { ) 01 ( )-02 t ) 03 { ) 01 ( ) 02 ( ) 03 f ) 01 ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 t 3 01 t ) 02 ( ) 03 { ) 01" (' ? 02 ( ) 03 { ) 01 ( ) 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE' LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND: TO TH£ BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FIISNO (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE C"TACT ;PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID'# ( ) 61 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2 i