COMPLIANCE INFO_1986-2003 - Laserfiche WebLink

Home Browse Search

STATE ID NUMBER CONTAINER CONSTRUCTION E. t D 01 RUBBER LINED ( ) 02 ALKYD LINING ( D 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED ( 108 UNKNOWN ( ) 09 OTHER: F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( D 04 UNKNOWN ( 1 05 NONE ( ) 06 TAR OR ASPHALT t ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN (X) 07 NONE B. UNDERGROUND PIPING: (X) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (x) 04 PP,ESSURE ( D 05 SUCTION t ) 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION ( l 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS (Xl 05 SENSOR INSTRUMENT ( ,) 06 GROUND WATER MONITORING WELLS [ ) 07 PRESSURE TEST t D 09 NONE ( ) 10 OTHER: 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 ("'1 O1 ( ) 02 ( ) 03 ( D 01 ( 1 02 O 03 ( 1 01 ( ) 02 ( 1 03 1 1 H I I I I I ( ' 01 O02 ( ' 0- iIIIiIIIiIIII t ) 01 ( D 02 ( l 03 ( 1 1 1 1 1 ( ' 01 t D02 ( 103 1N 1 1 1 1 1 111 ( ' 01 ( , 02 ( ) 03l 1101 ( ' 02 ( t03 _[_LIIIIIIIIIII ( 01 ( ) 02 ( ) 03_1 1 1 1 1 1 1 1 1.1 1_1 ( 101 ( 1 02 O 03 1 1 1 1 1 1 1 1 1 1 1 1 1 �IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (OCD 02 NO (THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. TPERSON FILING (SIGNATURE) n PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY AOMI)tISTPATING AGENCY CITY CODE COUNTY CODE CONTACT PERSON PHONE W/AREA CODE 4 )DATE OF LAST INSPECTION IN COMPLIANCE PERM$T APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID M ( ) 01 YES ( ) 02 NO 4SC04-070185 PAGE 2