COMPLIANCE INFO_1986-2005 - Laserfiche WebLink

Home Browse Search

STATE ID NUMBER 00000054576002 CONTAINER CONSTRUCTION E. '( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING { 104 PHENOLIC LINING ( } 05 GLASS LINING (X:) 07 U14LINED ( ) 08 UNKNOWN ( D 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( } 02 VINYL WRAPPING E ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( } 05 NONE ( ) '06 TAR OR ASPHALT ( ) 09 OTHER= VI PIPING A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN (` ) 07 NONE S. UNDERGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE (X) 05 SUCTION t ) 06 UNKNOWN '( ) 07 NONE VII LEAK DETECTION f l 01 VISUAL ( ) 02 STOCK INVENTORY- ( ) 04 VAPOR SNIFF WELLS f D 05 SENSOR INSTRUMENT ( D 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE ( l 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU APE NOT REgUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# IIF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STOPED STORED ( ) 01 ( ) 02 ( ) 03 X01 ( ) 02 ( ) 03 t D 01 ( ) 02 ( ) 03 t } 01 ( ) 02 ( ) 03 ( } 01 ( ) 02 ( ) 03 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 D 01 ( ) 02 ( ) 03 ( D 01 ( ) 02 ( ) 03 ( ) 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 BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON PIL%N (SIGNATUR ) PHONE W/AREA CODE 2 ) 33Y- I FOR L C A NCY 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 IA # ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2