COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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STATE ID NUMBER 00000039602001 CONTAINER CONSTRUCTION E. (' ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING; ( ) 04 PHENOLIC LINING f l 05 GLASS LINING t ) 07 UNLINED (Y,) 08 UNKNOWN ( l 09 OTHER: -jF. t ) 01 POLYETHLENE WRAP t D 02 VINYL WRAPPING t l 03 CATHODIC PROTECTION f ) 04 UNKNOWN (X) 05 NONE ( 3 06 TAR OR ASPHALT t ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE t l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) VQ 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( D 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X)04 PRESSURE t ) 05 SUCTION ( ) 06 UNKNOWN t l 07 NONE VII LEAK DETECTION (X) 01 VISUAL (X) 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS (X) 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 (00 NOT USE COMMERCIAL NAME) STORED STORED ( )' 01 ( ) 02 ( ) 03 ( ) 01 t ) 02 ( ) 03 f I 01 ( ) 02 ( ) 03 t ? 01 ( 1 02 ( ) 03 t I 01 t ) 02 ( ) 03 ( ) 01 { ) 02 ( ) 03 ( ? 01 t D 02 ( ) 03 t D 01' t ) 02 ( ) 03 E ) 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 KNOWLEDGEP IS TRUE AND CORRECT. PERSON FILINGG (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE �CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES '( ) 02 NO HSC04-070185 (10/18/85) PAGE 2