COMPLIANCE INFO_1986-1989 - Laserfiche WebLink

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0 STATE ID NUMBER CONTAINER CONSTRUCTION E. ( D 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING t ) 05 GLASS LINING ( ) 07 UNLINED 00 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP t ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (M-04 UNKNOWN t ) 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 PRESWRE ( ) 05 SUCTION t D 06 UNKNOWN ( 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ') 04 PRESSURE ) 05 SUCTION ( D 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT'S ( ) 06 GROUND WATER MONITORING WELLS 07 PRESSURE TEST ( l 09 NONE ( D 10 OTHER VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS- IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIP.EO TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED O01 O02 O03IIIIIIIIIIIII _ -- ( D01 ( ) 02 t ) 031 1 1 1 1 1 1 1 1 1 1 1 1 t D 01 ( ) 02 ( ) 03 L1111.1_I.1_I_I I I I - ( ) 01 O 02 O 03 1 1 1 1 1 I I I I I I I I -_-- ( ) 01 ( ) 02 ( ) 03 1 1 LL-LI I I I I I O01 t ) 02 () 03 ( ) 01 ( ) 02 ( ) 03 ( D 01 ( ) 02 ( ) 03 f 1 O01 O02 O03111II4IIIl1II ( D01 t ) 02 O03111IIIIIIIIII 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 CITY CODE COUNTY CODE SAN JOA4111N LOCAL HEALTH DISTRICT CONTACT PERSON PHONE W/AREA CODE _] DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ) 02 NO HSC04-070185 PAGE 2