COMPLIANCE INFO_1986-1990 - Laserfiche WebLink

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STATE ID NUMBER CONTAINER CONSTRUCTION E. ( l 01 BBER LINED ( ) 02 ALKYD LINING t D 03 EPDXY LINING ( ) 04 PHENOLIC LINING t D 05 GLASS LINING ( 0�07 UNLINED t D 08 UNKNOWN t ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( 102 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( D 04 UNKNOWN (-Y65 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND P%PING: ( ) 01 DOUBLE-WALLED PIPE t ) 02 CONCRETE-LINED TRENCH ( 03 GRAVITY (CHECK APPROPRIATE BOXES) (-) 04' PRESSURE ( D 05 SUCTION ( D 06 UNKNOWN t ) 07 NONE B. UNDERGROUND PIPING: (%1)41 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH t ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( D 04 PRESSURE ( ) 05 SUCTION t D 06 UNKNOWN ( ) 07 NONE VII LEAK DETECTION ( 0'1051 VISUAL ( ) 02 STOCK INVENTORY t ) 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS t 1 07 PRESSURE TEST ( 109 NONE ( D 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED'YES TO IV-R YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS(D (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED t ) 01 t ) 02 O 03 ( 1 I I I I I I I I ! I I 01 ( ' 02 ( ) 03 I I I I I I I I I I I I I ( ) 01 ( ) 02 ( ) 03 01 ( ) 02 t ' 03I O 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( ) 01 t ) 02 ( ) 031 1 1 I 1 1 1 1 1 1 1 ! I O01 c ) 02 ( ) 03 t D 01 ( ) 02 ( ) 03 I IS CUFtTAIHER LOCATED ON AN AGRICULTURAL FARM? t 101 YES t0--ri NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. r ERSON LING SIOURE) PHONE W/ARE ODE Ly -,4(rav r Fy R, �J4uc... FO LOCAL AGENCY US ONLY ADMINISTRATING AGENCY <: CITY C E COUNTY CODE _ I ---- --- j CONTACT P RSON PHO EW/ARE CODE j 36 S5 i a 17 DATE OF LAST INSPECTION FIN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 u ( ) 01 YES t D 02 NO HSC04-070185 PAGE 2