COMPLIANCE INFO_1993-1994 - Laserfiche WebLink

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STATE ID NUMBER 00000024100003 CONTAINER CONSTRUCTIOi E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING t } 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( l 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( D 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN t 105 NONE ( ) 06 TAR OR ASPHALT ( D 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: { ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION t ) 06 UNKNOWN ( ) 09 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION t ) 06 UNKNOWN t ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT } 06 GROUND WATER MONITORING WELLS t ) 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 (DO NOT USE COMMERCIAL NAME) STORED STORED t ) 01 ( 102 ( ) 03 ( D 01 ( ) 02 ( ) 03 t ) 01 t ) 012 ( ) 03 t ) 01 c ) 02 c ) 03' ( l 01 ( ) 02 ( ) 03 ( ) 01 ( } 02 ( ) 03 ( D 01 ( ) 02 ( ) 03 l 01 ( ) 02 ( ) 03 t l 01 t ) 02 ( ) 03 01 ( )-02 ( ) 03 CHECK STATE BOARD CH=EMICAL 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 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 INSPECTIONIN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 # 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2