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%Me .i <br /> STATE ID NUMBER 00000056211001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ! 01 RUBBER LINED ( ) 02 ALKYD LINING f 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> (X1 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( )-06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN 07 NONE <br /> B. UNDERGROUND PIPING- ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION f ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( I <br /> 01 VISUAL (X) 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS .20 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 /> f ) 01 ( ) 02 ( ! 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) O1 ( ) 02 f 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> al ( ) 02 f 1 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> 1 ) 01 1 ) 02 f ) 03 <br /> f 1 01 ( ) 02 f l 03 <br /> ( 1 <br /> 01 ( ) 02 ( 7 03 <br /> ( ) <br /> 01 ( ) 02 f ) 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PS FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ON' Y <br /> ADMINISTRATING AGENCY SAN JOAQUIN LOCAL HEALTH DISTRICT CITY CODE - CONY CODE <br /> r..» <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE IOCAI PERMIT IO # <br /> ( 1 01 YEAS ( 1 02 NO <br /> HSC04-070185 (10/18/85) + " PAGE 2 <br />