COMPLIANCE INFO_1985-1996 - Laserfiche WebLink

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STATE ID NUMBER 00000011082003 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. (X) 01 POLYETHLENE WRAP t l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ] 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( l 06 UNKNOWN ( l 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS 06 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 STORED t ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 f } 03 ( ) 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. PEP.SON FILING (SIGNATURE) PHONE W/AREA CODEWli (' _ �� o b FOR LOCAL AGENCY USE ONLY ADM;IISSTRATI�j,^.-AGENCY. G'j ) CITY CODE COUNTY CODE CONTACT Q �N PHONE19W/ RE ;DE 7 !,3 r 6 DAT F�i�AST4IjtS�P CTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # / �/ {O ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2