COMPLIANCE INFO_1986-1989 - Laserfiche WebLink

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STATE ID NUMBER CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( D 03 EPDXY LINING ( ) 04 PHENOLIC LININ ( ) 05 GLASS LINING t ) 07 UNLINED 8 UNKNOWN ( D 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION 04 UNKNOWN t D 05 NONE ( D 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING h A. ABOVEGROUND PIPING: t ) 01 DOUBLErWALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRES,�!RE ( D 05 SUCTION ( l 06 UNKNOWN 04-07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE=WALLED PIPE ( J 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ') 04 PRESSURE (>"S SUCTItN1 ( D 06 UNKNOWN ( l 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (>rlft STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMEI47vr ( D 06 GROUND WATER MONITORING WELLS ( 7 PRESSURE TEST ( ) 09 NONE ( D 10 OTHER:. a 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 CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) - STORED STORED ( ) 01 ( ) 02 ( ) 03 ( D 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 I I I I 1 ( D 01 O 02 O 03 I I I I I I I I ( ) 01 ( ) 02 ( ) 03 Ll I I H ( ) 01 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 11 ( ) 01 ( ) 02 ( ) 03 l ( ) 01 ( ) 02 ( ) 03 1 I I O 01 O 02 O 03 I I 1 I I I l H I I 1 1.—__ IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES ( 2 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 SAN JOAQUIN LOCAL HEALTH DISTRICT CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ZD 34 ( ) 01 YES ( ) 02 NO HSC04-070185 PAGE 2