COMPLIANCE INFO_1986-1995 - Laserfiche WebLink

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STATE ID NUMBER 00000013318001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( l 04 PHENOLIC LINING ( l 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 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) (4 04 PRESSURE ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE (X) 10 OTHER: LINE LEAK DETECTORS VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STOPED ( ) O1 ( ) 02 ( ) 03 f ) 01 ( ) 02 ( ) 03 ( l 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 f ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 t ) 01 ( ) 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO THIS FORM HAS WN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PvPSON FI (SIGNAT ) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY /�/ ADMINIf2�G AGENCY A N /,4 /� / �G�G i/`s' CITY CODE COUNTY CODE ,); CONTACT PERSON � ! w PHONE EA CODE_ DATE OF LAST INSPECTIO I IN COMPLIA✓NCE PERMIT APPROVAL DATE TRANSACTIIOO-N DATE LOCAL PERMIT ID # �- 2-3 4 ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2 i