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~ STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER lINEO [ ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED 1 08 UNKNOWN l ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f 1 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION l}d 04 UNKNOWN f 1 05 NOME <br /> 1 1 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: I ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN WQJ7 NONE <br /> B. UNDERGROUND PIPING: f 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( •1 04 PRESSURE .2�.05 SUCTION f ) 06 UNKNOWN f 1 07 NONE <br /> VII LEAK DETECTION <br /> l 1 O1 VISUAL �(10 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS l ) 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND NATER MONITORING WELLS 00 07 PRESSURE TEST ( 1 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 11 O1 ( 1 02 ( 1 03 <br /> ( ) 01 ( 1 02 ( ) 03 I I I_111111J_I I _ _ --- <br /> 1 1 O1 ( ) 02 ( ) 03 <br /> 1 1 01 1 1 02 f' I' 03 I I I I I 1 1 <br /> 1 ) Ol ( 1 02 O 03 1 1Ll LI I I I I 1 1 <br /> ( ) <br /> 01 1 ) 02 ( 1 03 <br /> O O1 ( 1 02 ( 1 03 <br /> f 1 <br /> 01 ( ) 02 [ ) 03 I I <br /> ( 1 01 1 ) 02 ( 1 03 <br /> l ) 01 f ) 02 l ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ] 01 YES ��Z NO —� <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILI41111TIPE) PHONE W/AREA CODE <br /> O6 3G <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATINO AGENCY CITY CODE COVNTY CODE <br /> SAN JOAOUIN LOCM. HEALTH DISTRItX <br /> CONTACT PERSON cPHONE W/ARCA CODE <br /> ,e_ 20 - <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID S <br /> C 1 1 01 <br /> YES <br /> ],�0[2 NO <br /> 2Cf4-070185 d �� 1 , 7V-S PAGE 2 <br />