COMPLIANCE INFO_1986-1989 - Laserfiche WebLink

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STATE ID NUMBER CONTAINER CONSTRUCTION' E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING f ) 04 PHENOLIC LINING t D 05 GLASS LINING ( ) 07 UNLINED (%,J-"08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP t D 02 VINYL WRAPPING ( D 03 CATHODIC PROTECTION 04 UNKNOWN ( D 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 BOX(ES) ( ) 04 PRE RE ( ) 05 SUCTION t 1 06 UNKNOWN (3d'07 NONE r B. UNDERGROUND PIPING: ( l 01 DOUBLE WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE 05 SUCTION t ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION t ) 01 VISUAL ( 2 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS t D 05 SENSOR INSTRUMERT t ) 06 GROUND WATER MONITORING WELLS (kT 07 PRESSURE TEST t ) 09 NONE t l 10 OTHER-t—_ 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 CASO (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STORED t ) 01 ( ) 02 ( ) 03 I I I I ( I I I I I I ( I ( ) 01 ( ) 02 ( ) 03 1 ( ) 01 ( ) 02 ( ) 03 X ( ) 01 t ) 02 ( ) 03 t ) 01 ( ) 02 t J 03 L 4 ) 01 ( ) 02 t J03 ( ) Ol ( ) 02 t ) 03 t ) 01O 0 2 O 03 I ) 01 ( ) 02 t l 03 r t ) 01 1102 t ) 03I � I [ IIII ( llll _ IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t ) 01 YES 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGEe IS TRUE AND CORRECT. PERSON FILING (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY SAN 10AQU!N! LOW. HEAL 'H DISTRIGS CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTIOGCOMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE TOCAL PERMIT ID 7S S ( ) 02 NO HSC04-070185 PAGE 2