COMPLIANCE INFO_1986-1989 - Laserfiche WebLink

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STATE ID NUMBER 00000037709014 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING t D 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP t D 02 VINYL WRAPPING ( D 03 CATHODIC PROTECTION kl 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( D 09 OTHER: VI PIPING A. ABOVEGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( D 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION 06 UNKNOWN ( 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE Po 05 SUCTION ( 106 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( J 01 VISUAL (X) 02 STOCK INVENTORY ( 104 VAPOR SNIFF WELLS ( D 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS K) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS I:F YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PP.EVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED ( 101 ( ) 02 ( ) 03 ( D 01 ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 ( 101 ( ) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 d D 01 ( ) 02 ( ) 03 ( D 01 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t ) 01 YES (X) 02 NO THIS FORM,NAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANOP TO THE BEST OF MY KNOWLEDGE: IS TRUE AND CORRECT. PEF.SON FILING (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE SAN 1OAQUIN LOCAL HEALTH DISTRICT CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 # ( J 01 YES ( J 08 NO HSC04-070185 (10/18/85) PAGE 2