COMPLIANCE INFO_1995-2004 - Laserfiche WebLink

Home Browse Search

STATE ID NUMBER CONTAINER CONSTRUCTION E. ( ) O1 BER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING ( 0 07 UNLINED ( D 08 UNKNOWN t D 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( D 02 VINYL WRAPPING ( D 03 CATHODIC PROTECTION t ) 04 UNKNOWN (-Y-Vi NONE ( D 06 TAR OR ASPHALT ( D 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( D 02 CONCRETE-LINED TRENCH 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04' PRESSURE ( D 05 SUCTION ( ) 06 UNKNOWN ( l 07 NONE I B. UNDERGROUND PIPING: (VDf1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH t 103 GRAVITY _ (CHECK APPROPRIATE BOX(ES) ( D 04 PRESSURE t ) 05 SUCTION ( D 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( bY01 VISUAL ( D 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( D 06 GROUND WATER MONITORING WELLS ( D 07 PRESSURE TEST ( l 09 NONE ( 110 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 CASA (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STORED ( D01 ( ) 02 ( D03I ( ) 01 ( ) 02 ( 1031 1 111 i i l l l i l l ( ) 01 () 02 ( 1031 1 111 1 1 � 11 1 1 1 ( 1 01 ( ) 02 O 03 ( ) 01 ( ) 02 ( ) 03 O01 ( ) 02 ( ) 03 I I I I I I I I I I I O of ( ) 02 O 03 ( ) 01 t D 02 ( ) 03 j O 01 O 02 t D 03 O01 ( 102 03IIIIIIillllii I LSCCNTAINER LOCATED ON AN AGRICULTURAL FARM? ( D 01 YES ( 0-62 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. tkx SIO URE) PHONE W/ARE ODE i ww�e FORLOCAL�A CY US ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE i I DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 0 f > O1 YES ( l 02 NO HSC04-070185 PAGE 2