COMPLIANCE INFO_1985-1997 - Laserfiche WebLink

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STATE ID NUMBER 00000039604001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED t D 02 ALKYD LINING t ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING t D 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN t ) 09 OTHER= F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER= VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH t ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE` ( l 05 SUCTION d ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: t ) 01 DOUBLE—WALLED PIPE ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( D 05 SUCTION ( ) 06 UNKNOWN f ) 07 NONE VII LEAK DETECTION (X) 01 VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT i 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( ) 09 NONE ( D 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIAL'S 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 STCFED ( ) 01 ( l 02 ( ) 03 t D01 ( l 02 ( ) 03 t ) 01 t l 02 ( ) 03 ) O1 ( ) 02 ( ) 03 ( ) 01 ( l 02 ( ) 03 ( ) 01 ( l 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 C ) 01 ( l 02 ( ) 03 ( ) 01 t ) 02 ( ) 03 t ) 01 ( ) 02 ( } 03 # CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( l 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 t NO (SIGNATUP.E) PHONE W/AREA CODE. FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE I 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