COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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CONTAINER CONSTRUCTION S 9 STATE ID 'NUMBER E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 --PHENOLIC LINING ( ) 05 GLASS LINING I) ( ) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (j 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING- ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY `• (CHECK APPROPRIATE BOXES) ( ) 04' PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE t ) 02 CONCRETE—LINED TRENCH X) 03 GRAVITY (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE 40 05 SUCTION ( ) 06 UNKNOWN ( ) 07NONE VII LEAK DETECTION ( ) 01 VISUAL ( 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT I ( ) 06 GP,OUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( 1 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 STORED DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) c l 01 O 02 ( 1 03 (I I I I I I I I I I I I ( )01 ( )02 ( )031 1 1 11 11 111 1 1 1 ( ) 01 ( ) 02 ( ) 03 i I I I I I LLL1�1_I t) 01 O 02 O 03 ( ) 01 ( ) 02 t ) 003 ( )01 ( )02 ( )03 LlI I I I I I I I I I ( )01 ( )02 ( )03i l l l l l l l l l l l l f ) 01 ( ) 02 ( ) 03 O01 (IO2 O031II��Iiilllll ( ) 01 ( 1 02 ( ) 03 I I ( I LSC�NTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (,k 02 NO PMIS FOR. AS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. P - I ( NAT PE) / PHONE W/AREA CODE cit /S )P. LOCAL AGENCY USE ONLY ADMINISTPAT G AGENCY CITY C E COUNTY CODE CONTAC PHO/NE W /AR A COQE� DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( l 02 NO HSC04-070185 • PAGE 2