COMPLIANCE INFO_1985-1996 - Laserfiche WebLink

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STATE ID NUMBER 00000011082001 CONTAINER CONSTRUCTION E. # ) 01 RUBBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. (X) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING t d 03 CATHODIC PROTECTION ( d 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT t ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE — ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: E ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION t ) 01 VISUAL (X) 02 STOCK INVENTORY E ) 04 VAPOR SNIFF WELLS E 105 SENSOR INSTRUMENT t ) 06 GROUND'WATER MONITORING WELLS ) 07 PRESSURE S ( ) 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 (00 NOT USE COMMERCIAL NAME) STORED STORED 01 t ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 f ) 01 ( ) 02 ( l 03 ( ) 01 ( ) 02 t ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 t 3 01 ( ) 02 ( ) 03 { l 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/AREA CODE I u ), �L �a�6A� 1s FOR LOCAL AGENCY USE ONLY _T A.DMINI TRATING A NCY CITY CODE COUNTY CODE CONTACT PERSON_— PHO E W/A A CODE DATE Of/ LAST NSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # �' ( ) 01 YES ( ) 02 N0 HSC04-070185 (10/18/85) PAGE 2