COMPLIANCE INFO_1986-1989 - Laserfiche WebLink

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r STATE ID NUMBER CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING 1 ) 03 EPDXY LINING t D 04 PHENOLIC LININ ( 105 GLASS LINING ( ) 07 UNLINED (,%."8 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f 103 CATHODIC PROTECTION t 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( D 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE�-WALLEO PIPE ( D 02 CONCRETE-LINED TRENCH ( D 03 GRAVITY (CHECK APPROPRIATE BOX(ES) t ) 04 PRESWRE t ) 05 SUCTION ( ) 06 UNKNOWN x' 07 NNE 4 B. UNDERGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH OCT 03 GRAVITY (CHECK APPROPRIATE BOX(ES) t ') 04 PRESSURE ( ) 05 SUCTION ( D 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION t 101 VISUAL [ ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR IHSTRUMEAT'va ( ) 06 GROUND WATER MONITORING WELLS t ) 07 PRESSURE TEST (±x'09 NONE ( 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 CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) _ STORED STORED ( 101 02 ( D 03 NAIIIIIIIIII _ ( ) 01 ( 02 t ) 03 t D of O 02 t ) 03 1 1 1 1 1t 1 1 1 1 1 1 1 1 O 01 O 02 ( D 03 1 1 1 1 1 1 t D 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03i 10 O02 O03Ii11IflIIiil [ ( D 01 ( ) 02 ( ) 03 I I i D 01 t ) 02 ( ) 03 ( ) 01 ( ) 02 ( 1031 1 1 1 1 1 1 1 1 1 1 1 1 IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( D 01 YES t 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 CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMYT ID # ( l 01 YES ( P 02 NO HSC04-070185 PAGE 2