COMPLIANCE INFO_1985-1992 - Laserfiche WebLink

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STATE ID NUMBER 00000023560004 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING t } 03 EPDXY LINING ( l 04 PHENOLIC LINING ( ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETWLENE WRAP t d 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION f D 04 UNKNOWN (X) 05 NONE ) .06 TAR OR ASPHALT ( ) 09 OTHER VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 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 BOXCES) (X) 04 PRESSURE ( l 05 SUCTION ( 06UNKNOWN ( 107 NONE VII LEAK DETECTION 01 VISUAL fX) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT t ) 06 GRCUND WATER MONITORING WELLS { d 07 PRESSURE TEST ( ) 09 NONE (X) 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 1CURPENTIY PREVIOUSLY DELETE OAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) L_STORED STORED �( ) 01 ( ) 02 ( ) 03 t 01 x ) 02 O03lII1IIIIIiIII { f ) 01 t ) 02 ( ) 03 I t ) Ol (. ) 02 ( ) 03 01 t ) 02 ( ) 03 ( ,..L, ( ) 02 ( ) 03 { 01 (' ) 02 ( ) 03 ( ( 01 ( l 02 ( ) 03 01 t ) 02 ( ) 03 l O1 ( ) 02 ( ) ,03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CON'(AINEk_LOCATED ON AN AGRICULTURAL FARM? ( 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. r - 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 ID # ( ) 01 YES ( ) 02 NO IISC04-070185 (10/18/85) PAGE 2