COMPLIANCE INFO_1986-1989 - Laserfiche WebLink

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STATE ID NUMBER 00000.037709008 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( } 05 GLASS LINING fX) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER= F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING E 8 03 CATHODIC PROTECTION ki 04 UNKNOWN f } 05 NONE t ) 06 TAROR ASPHALT ( } 09 OTHER- VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION 06 UNKNOWN (Al 07 NONE 8. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (N 05 SUCTION ( ) 06 UNKNOWN ( } 07 NONE VII LEAK DETECTION t 3 01 VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( } 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS 07 PRESSURE TEST ( ) 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 PPEVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED t ) 01 ( ) 02 E 3 03 t l 01 ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 E ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( } 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 t ) 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. PERSON FILING (SIGN.ATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY SAN JOMQUIN/V:+Lf„OC.AL..L..HEALTH. D-`JST'nR:ICT CITY CODE COUNTY CODE CONTACT PERSON PHONE WIAREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT TO # ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18185) PAGE 2