COMPLIANCE INFO_1985-1996 - Laserfiche WebLink

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STATE ID NUMBER 00000011082002 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING t } 04 PHENOLIC LINING ( l 05 GLASS LINING I ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. (X) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION t ) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 0-1 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE t ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALSSTORED IN UNDERGROUND CONTAINERS I'F 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) STO;ED STORED t ) 01 O 02 O 03 t ) 01 ( )-02 ( ) 03 01 ( ) 02 ( ) 03 t ) 01 ( )-02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( l 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) uci_4L C6,�� PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMI ISTRATIN AGENCY / CITY CODE COUNT CODE CONT CT 7P N P ONE W AR CODE DATE 060 LA T�SPECTION IN COMPLIANCE ];;;MIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 20 # J/ ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2