COMPLIANCE INFO_1986-1989 - Laserfiche WebLink

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STATE ID NUMBER CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING l ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED ( 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP t D 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION 1>4 04 UNKNOWN t D 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER= VI PIPING A. ABOVEGROUND PIPING: ( l 01 DOUBLE!-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRES,WRE ( D 05 SUCTION ( ) 06 UNKNOWN 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-'WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL t 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT'^.ar; ( ) 06 GROUND WATER MONITORING WELLS 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHERt 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 CASA (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED t101 O02 O0311111111111N ( ) 01 ( ) 02 ( ) 03 02 O 03 I I IJ l i i l f l l ( 102 O03IIIIIIIIINII ( ) Ol t ) 02 ( ) 03 LLLU i ( ) 01 t ) 02 ( ) 03 I l IJ I I_I I i N ( D01 ( ) D2 ( ) D3 1 1 1 LL1 1 1 1 1 1 t ) Ol ( ) 02 ( ) 03 ( ) Ol ( ) 02 ( ) 03 �. O 01 O 02 O 03 1 1 1 1 1 { I l f l l l l IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES 02 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 JOAQ UIN LOCaL HFA LIH DISTR-V CITY CODE COUNTY CODE CONTACT P!P.SON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATETRANSACTION DATE LOCAL PERMIT ID A ( 1 01 YES ( ) 02 NO HSC04-070185 PAGE 2