COMPLIANCE INFO_1995-2002 - Laserfiche WebLink

Home Browse Search

STATE ID NUMBER 00000046037003 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING E D 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETH LENE WRAP t ) 02 VINYL WRAPPING t D 03 CATHODIC PROTECTION t ) 04 UNKNOWN t ) 05 NONE (X) 06 TAR OR ASPHALT { ) 09 OTHER VI PIPING A. ABOVEGROUND PIPING ( ) 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- t ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( 3 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN t ) 07 NONE VII LEAK DETECTION W3 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( T 06 GROUND WATER MONITORING WELLS ( l 07 PRESSURE TEST t ) 09 NONE ( ) 10 OTHER= VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV -F YOU APE NOT P.EQUIPED TO COMPLETE THIS SECTION CURRENTLY STOPED PREVIOUSLY STORED DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ), 02 ( ) 03 f l 01 ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 ( J 01 ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 f ) 03 t ) 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO CHIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FI G iSIGNA R ) PHONE WlAf2EA G E .� R LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE CONTA T PERSON PHONE W/AREA CODE SATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2