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i' s./ STATE ID NUMBER 00000066266001 CONTAINER CONSTRUCTION E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( l 04 PHENOLIC LINING ( ) 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: F. 1 ) 01 POLYETHLENE WRAP 1 ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLEDPIPE ( l 02 C RETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE ( ) 05 SUCTION 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ] 06 UNKNOWN l ) 07 NONE VII LEAK DETECTION (X) 01 VISUAL PC) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS (AQ 07 PRESSURE TEST ( ) 09 NONE ( ) 30 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-P YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STORED ! ) 01 ( 1 02 ( ) 03 ( ) 01 ( ) 02 ( 1 03 ( ) 01 ( ) 02 ( ) 03 f 1 01 ( l 02 f ] 03 l 1 01 ( l 02 ( ) 03 ( ) 01 ( l 02 ( 1 03 l ) 01 ( l 02 ( ) 03 ( 7 01 I 1 02 f ) 03 ( l 01 ( 1 02 ( ) 03 ( ) 01 ( ) 02 l ) 03 • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS I5 CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING AGENCY CITY CODE COUNTY CODE San Joaquin Local Health District 1 39 CONTACT PERSON PHONE W/AREA CODE Ken Belcher20q-944-2275 DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 # 9-9s-196 1 ( ) 01 YES ( ) 02 NO • HSC04-070185 (08/29/861 M.A. #8 PAGE 2