COMPLIANCE INFO_1985-1998 - Laserfiche WebLink

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STATE ID NUMBER 00000057932001 CONTAINER CONSTRUCTION E. E D 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING E l 04 PHENOLIC LINING, ( ) 05 GLASS LINING t } 07 UNLINED (X) 08 UNKNOWN ( D 09 OTHER F. ( ) 01 POLYETHLENE WRAP ( } 02 VINYL WRAPPING E ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE t ) 06 TAR OR ASPHALT t ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING= t ) 01 DOUBLE—WALLED PIPE t 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( )- 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE t ) 05 SUCTION ( l 06 UNKNOWN ( } 07 NONE VII LEAK DETECTION (X) 01 VISUAL ( ) 02 STOCK INVENTORY t D 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS t ) 07 PRESSURE TEST ( i 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 l 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 r ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( D 01 ( ) 02 ( ) 03 f 101 ( ) 02 ( ) 03 ( } 01 ( ) 02 ( ) 03 { ) 0.1 ( ) 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 ANDa TO THE BEST OF MY KNOWLEDGE: IS TRUE AND CORRECT. PERSON FILING (SIGNATURE). PHONE W/AREA CODE a a FOR LOCAL AGENCY USE ONL ADMINISTRATINY AGENCY ( l ( GZTY p COUNTY CODE CONTACT PEP. ON l Q t PHO E W/AP A CODE c t 6 DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES t ) 02 N0 HSC04-070165 (1.0/18/85) PAGE 2