COMPLIANCE INFO_1985-1999 - Laserfiche WebLink

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STATE ID NUMBER 00000001798002 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LIKED t D 02 ALKYO LINING 03 EPDXY LINING 04 PHENOLIC LINING 05 GLASS LINING 07 UNLINED (X) 08 UNKNOWN 09 OTHER: F. ( ) 01 POLYETHLENE WRAP 02 VINYL WRAPPING 03 CATHODIC PROTECTION (X) 04 UNKNOWN 05 NONE ( ) 06 TAR OR ASPHALT 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ) 01 DOUBLE-WALLED PIPE 02 CONCRETE-LIKED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE OS SUCTION (X) 06 UNKNOWN 07 NONE B. UNDERGROUND PIPING! t ) 01 DOUBLE-WALLED PIPE 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE t D 05 SUCTION ( 06 UNKNOWN 07 NONE VII LEAK DETECTION (X) 01 VISUAL ( ) 02 STOCK INVENTORY 04 VAPOR SNIFF WELLS 05 SENSOR INSTRUMENT ( ) 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# TIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED (X) 01 ( ) 02 ( 03 ASPHALT, LIQUIQ."Sui0, 01 ( ) 02 ( l 03 01 ( ) 02 ( 01 01 ( ) 02 ( 03 01 ( ) 02 ( D 03 01 ( ) 02 ( 03 01 ( ) 02 ( 03 1 01 ( ) 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 THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (SIGNATURE) PHONE W/ARZA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON I PHONE W/APEA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # 01 YES 02 NO 7, HSC04-070185 (10/18/85) ,," PAGE 2