COMPLIANCE INFO_1989-2001 - Laserfiche WebLink

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STATE ID NUMBER 00000062598004 CONTAINER CONSTRUCTION ( ) 01 RUBBER LINED i l 02 ALKYD LINING ( l 03 EPDXY LINING ( l 04 PHENOLIC LINING ( ] 05 GLASS LINING (X) 07 UNLINED ( l 08 UNKNOWN ( ) 09 OTHER: ( ) 01 POLYETHL€NE WRAP ( 1 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT t ) 09 OTHER: VI PIPING �. ABOVEGROUND PIPING: ( J 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( l 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN k�-r07 NONE L UNDERGROUND PIPING: ( ) 0.1 DOUBLE -WALLED PIPE ( 1 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN 007 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS W 07 PRESSURE TEST t l 09 NONE ( l 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 STORED PREVIOUSLY STOPED DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) ( ) 01 ( ) 02 ( ) 03 [ ) 01 ( ) 02 ( ) 03 [ l 01 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) Q3, ( ) 01 ( ) 02 ( ) =03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS ES CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO THIS M HAS BEEN COMPLETED UNDER THE .PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PEP.N F LINC3 ( SIGNATPR) J PNS W/AREA r 'j Jm v FOR LOCAL AGENCY USE ONLY ADMINISTRATING .AGENCY n -t CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID St ( ) 01 YES, ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2