COMPLIANCE INFO_1986-1989 - Laserfiche WebLink

Home Browse Search

STATE IO NLRIBER CONTAINER CONSTRUCTION E. t ) Ol RUBBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING t ) 04 PHENOLIC LINING ( ) 05 GLASS LINING d ) 07 UNLINED (� 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP t D 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION (.4-04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( 103 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRES'WRE ( ) 05 SUCTION ( D 06 UNKNOWN 00707 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( •) 04 PRESSURE 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL C-0-02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( D 05 SENSOR INSTRUMEWT ( ) 06 GROUND WATER MONITORING WELLS P<f 07 PRESSURE TEST ( l 09 NONE ( ) 10 OTHER-;- VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS _ IP YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) _ STORED STORED O 01 O 02 ( 03 1 1 1 1 1 1 1 1 1 1 1 1 1 ( D Ol ( ) 02 ( D 03 ( ) 01 () 02 00311111 1 111 1 1 11 ( l 01 () 02 ( 03 ( ) 01 ( ) 02 ( ) 03 1 1 LLL O01 t ) 02 ( 1031 I i 1 I I I i i I I IJ t H01 ( ) 02 ( ) 031 1 1 1 1 1 1 1 1 1 1 11 t ) 01 O 02 1 1 03 1 I l l l l l l l l l l l t ) 01 ( ) 02 ( ) 031 t ) 01 ( l02 ( ) 031111111111111 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 SAN 10AQUI LOCAL HEALTH DISTRICT CITY `ODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) O1 YES ( ) 02 NO HSC04-070185 PAGE 2