COMPLIANCE INFO_1985-1992 - Laserfiche WebLink

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STATE ID NUMBER 00000023560003 CONTAINER CONSTRUCTIOW E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING E ) 03 EPDXY LINING ( l 04 PHENOLIC LINING t ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP t ) 02 VINYL WRAPPING ( } 03 CATHODIC PROTECTION ( l 04 UNKNOWN (X) 05 NONE ( ) 06 TAR OR ASPHALT t D 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: t ) 01 DOUBLE—WALLED PIPE f ) 0.2 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWNt ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXES) (X) 04 PRESSURE t ) 05 SUCTION E ) 06 UNKNOWN ( } 07 NONE VII LEAK DETECTION 0l VISUAL (X) 02 STOCK INVENTORY f ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT Ola GROUND WATER MONITORING WELLS t ) 07 PRESSURE TEST t ) 09 NONE (X) 10 OTHER: VIII CHEMICAL COMPOSITION OF MAT=ERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIREO TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STOPED ( ) 01 ( ) 02 t l 03 ( l 01 ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 ( ) 01 ( ) 0'2 ( ) 03 ( } 01 t- ) 02 f ) 03 (' ) 01 ( ) 02 ( ) 03 ( ) O f ) 02 ( ) 03 ( ) 01 i D 02 ( ) 03 t ) 01 f 102 ( ) 03 ( 1 01 t ) 02 ( l 03 # CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t ) 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANDP TO THE BEST OF MY KNOWLEDGEP IS TRUE AND CORRECT. PERSON FILING (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY' CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT TO # ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2