COMPLIANCE INFO_1986-1990 - Laserfiche WebLink

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STATE ID NUMBER 000000096SS004 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED t D 02 ALKYD LINING ( ? 03 EPDXY LINING t } 04 PHENOLIC LINING ( D 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING t D 03 CATHODIC PROTECTION t D 04 UNKNOWN (X) 05 NONE t ) 06 TAR OR ASPHALT E ) 09 OTHER VI PIPING A. ABOVEGROUND PIPING= t ) 01 DOUBLE—WALLED PIPE ( } 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE t ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: E ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE SOX(ES) (X) 04 PRESSURE C ) 05 SUCTION ( D 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( i 01 VISUAL (X) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS E } 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS t ) 07 PRESSURE TEST ( ) 09 NONE (X) 10 OTHER: LINE LEAK DETECTOR VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STORED f ) 01 ( ) 02 ( ) 03 f ) 01 ' ( ) 02 ( ) 03 ( 101 ( ) 02 ( ) 03 01 ( ) 02 t D 03 D 01 ( ) 02 ( ) 03 01 ( ) 02` ( ) 03 01 ( ) 02 t ) 03 ( ) 01 ( ) 02 ( J 03 ( ) 01 ( ) 02 ( D 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 COMP DER THE PENALTY OF PERJURY AND: TO THE BEST Of MY KNOWLEDGE: IS TRUE AND CORRECT. PERSON FILING (SIGNA UREI — PHONE W/AREA CODE R- -17 FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCYCITY CODE COUNTY CODE 3 CONTACT E-RSON a PHONE W/AREA C E 4=Tns. - 7 DATE OF LAST INSPECTION JIN COMPLIANCE PERMIT APPROVAL DATETRANSACTION:DATE LOCAL PERMIT 20 # ( ) 01 YES ( ) 02 NO HSC04-070185 (10/18/85) PAGE 2