COMPLIANCE INFO_1985-1998 - Laserfiche WebLink

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STATE ID NUMBER 00000059400002 CONTAINER CONSTRUCTION E. t ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING t ) 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN t 1 09 OTHER: F. ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING ( ? 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 0`9 OTHER VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( i 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE t } 05 SUCTION t } 06 UNKNOWN C ) 07 NONE VII LEAK DETECTION (X) 01 VISUAL ( ) 02 STOCK INVENTORY # ) 04 VAPOR SNIFF )SELLS ( ) 45.SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 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 STOPED t ) 01 (-) 02 ( ) 03 4 } 01 ( ) OE ( ) 03 t 101 ( ) 02 ( ) 03 )'01 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 t ;) 01 ( ) 02 ( ) 03 ( ) 01 t ) 0.2 ( ) 03 01 ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 t `) 01 ( ) 02 ( ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM'; ( J 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 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 IO # ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2