COMPLIANCE INFO_1985-1998 - Laserfiche WebLink

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STATE ID NUMBER 00000059400001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING t ) 04 PHENOLIC LINING ( ) 05 PLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( J 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE f D 06 TAR OR ASPHALT d -) 09 OTHER VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( l 02 CONCRETE—LINED TRENCH ( 1 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ') 04 PRESSURE ( ) 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: { ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES)' ( ) 04 PRESSURE ( ) 05 SUCTION t l 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( a 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING SELLS ( D 07 PRESSURE TEST E ) 09 NONE ( J 10 OTHER VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOUCHECKEDYES TO IV-P YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED ( ) 01 ( ) 02 t ) 03 ( ) 01 ( ) 02 ( ) 03 a 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 )-01 ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 E ) 01 ( ) 02 ( ) 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 AND: TO THE BEST OF MY KNOWLEDGEa IS TRUE AND CORRECT. PERSON FILING (SIGNATURE) ];;ONE 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 N0 HSC04-070185 (10/18/85) PAGE 2 i