COMPLIANCE INFO_1986-1997 - Laserfiche WebLink

Home Browse Search

STATE ID :NUMBER 00000036871002 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING t ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LININS ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING t l 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE ( ') 06 TAR OR ASPHALT t D 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 07 NONE B. UNDERGROUND PIPING: { ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VIZ LEAK D-ETECTION md 01 VISUAL02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT D 06 GROUND ER MONITORING WELLS 07 PRESSURE TEST 4 l 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO 2V-F YOU ARE NOT _RE4UIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STOPED ( D 0I ( ) 02 ( ) 03 ( ) 01 ( ) 02' ( ) 03 ( ) 02 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 , D OS (- ) 02 ( ) 03 ( D 01 ( ) 02 ( ) 03 ( 3 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t l 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 NG (SIGNAft ) PHONE W/APEA G OE Gl tm, '�-0 gel c FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY ® - CITY CODE COUNTY CODE 1 3 CONTACT PERSON PHONE W/�A/RE+Ay CODE y /"ac DATE OF LAST INSPECTION IN COMPLYAICE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # Y-3- ( ) O1 YES ( ) 02 NO HSC04-070185 (10/18/85) S PAGE 2