COMPLIANCE INFO_1986-1989 - Laserfiche WebLink

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qqml- STATE ID NUMBER 00000037709012 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING t ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP t ) 02 VINYL WRAPPING ( D 03 CATHODIC PROTECTION (X 04 UNKNOWN t ) 05 NONE 06 TAR OR ASPHALT { l 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE t D 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION ML 06 UNKNOWN ( 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE D,/) 05 SUCTION ( ) 06 UNKNOWN ( l 07 NONE VII LEAK DETECTION 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT t ) 06 GROUND WATER MONITORING WELLS (0v< 07 PRESSURE TEST ( D 09 NONE t ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED 'YES TO IV-F YOU APE NOT PECvUIRED TO COMPLETE THIS SECTION CUPRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STORED ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 { ) 01 ( ) 02 ( ) 03 ) 01 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 ) 01 ( ) 02 ( ) 03 t ) Ol ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03. t ) 01 ( ) 02 ( ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PEPSON FILING (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY SAN 10AOUEN LOCAL HFAITN nl(ZTPlrT CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION JIN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 20 # ( ) 01 YES ( ) 02 NO HSC04-070185 '(10/18/85) PAGE 2