COMPLIANCE INFO_1986-1993 - Laserfiche WebLink

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CONTAINER CONSTRUCTION STATE I® NUMBER 0000004271001 E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 7 04 PHENOLIC LINING f ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN t ) 09 OTHER F. ( ) 01 POLYETHLENE WRAP t } 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION ( } 04 UNKNOWN ( } 05 NONE (X:) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: E 1 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING ( 1 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION 01 VISUAL (X) 02 STOCK INVENTORY t i 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT f ) 06 GROUND WATER MONITORING WELLS t 1 07 PRESSURE TEST ( l 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 STORED PREVIOUSLY sSTOPED DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) ( 101 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 101 ( ) 02 (') 03 01 ( ) 02 ( ) 03 t ) 01 t ) 02 ( ) 03 01 ( ) 02 [ ) 03 [ ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 f ) 03 01 t ) 02 ( ) 03 * CHECK STATE BOARD CHEMICAL 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 FILIN 'GN.ATURE)PHONE WfAREA CODE - FOR LOCAL AGENCY USE ONLY ADMIN STRATI AC,ENCY CITY CODE COUNTY CODE CONTACT PERSO PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 # ( ) 01 YES t ) 02 NO HSC04-070185 (10118/85) PAGE 2 0 1p J