COMPLIANCE INFO_1986-1989 - Laserfiche WebLink

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STATE ID NUMBER CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED 02 ALKYD LINING 03 EPDXY LINING t ) 04 PHENOLIC LINING t ) 05 GLASS LINING ( ) 07 UNLINED �) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP 02 VINYL WRAPPING 03 CATHODIC PROTECTION (Ar 04 UNKNOWN 05 NONE 06 TAR OR ASPHALT 09 OTHER: VI PIPING A. ABOVEGROUND PIPING. 01 DOUBLEr-WALLED PIPE 02 CONCRETE-LINED TRENCH 03 GRAVITY (CHECK APPROPRIATE BOX(ES) 04 PRESWRE 05 SUCTION 06 UNKNOWN [-40_07 NONE B. UNDERGROUND PIPING: 01 DOUBLE-WALLED PIPE t l 02 CONCRETE-LINED TRENCH 03 GRAVITY (CHECK APPROPRIATE BOX(ES) 04 PRESSURE 0<Y 05 SUCTION 06 UNKNOWN 07 NONE VII LEAK DETECTION 01 VISUAL 02 STOCK INVENTORY 04 VAPOR SNIFF WELLS 05 SENSOR INSTRUMENT--,,,,,, 06 GROUND WATER MONITORING WELLS t P 07 PRESSURE TEST (,J<r 09 NONE 10 OTHER-• 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 OAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STORED 01 O02 03 01 oz 03 01 02 03 1 1. H I I I I I I O 01 ( 02 O 13 01 ( ' 02 ( 13 1 1 LLLLl i I I I I I 01 ( l02 ( 03 1 1 1 1 1 1 1 1 1 1 1 1 1 01 ( 02 ( 1 03 1111 1 11 1 1 1j H I I I 01 ( 02 ( ) 03 1 Ll I I I I I I I I I I 01 ( ) 02 ( 1 13 01 It ) 02 ( ) 03 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 IADMINISTPATING AGENCY SAN JOAQUIN LOCAL HEALTH DISTRICT c ITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE LOCAL- DATE OF LAST INSPECTION IN COMPLIANCE OVAL DATE TRANSACTION DATE L PERMIT ID # I ( ) 01 YES 02 NO HSC04-070185 PAGE 2