COMPLIANCE INFO_1986-1997 - Laserfiche WebLink

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STATE ID NUMBER 00000036871004 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( l 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( l 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH f j 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN _(e_Q7 NONE S. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 5,93 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE €A^5 SUCTION ( ) 06 UNKNOWN t 1 07 NONE VII LEAK DETECTION .,01 VISUAL �,,02 STOCK INVENTORY C ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT l 06 GROUND WATER MONITORING WELLS C�"7 PRESSURE TEST t ) 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 4CUPRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) j STORED STOPED 1 ( ) 02 ( ) 03 N99-64-Umff X01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 L( ) O1 ( ) 02 ( ) 03 i C ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ` ( ) 01 ( ) 02 ( ) 03 ) 01 ( ) 02 ( ) 03 * CHECK STATE BOARD CHEMICAL COBE 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 (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADM NIST RATING AGENCY CITY CODE COUNTY CODE To a Cry M CONTAC PERSO PHONE W/AREA CODE _2'! ,7 -23)_ DATE OF LAST INSPECTION JIN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) MW N PAGE 2