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.. .. .... .r . j JUN _qr <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> f ) 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 (X) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ] 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> 4_7 O1 VISUAL (X) 02 STOCK INVENTORY f 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-P YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASA (IF KNOWN) <br /> STORED STORED CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> ( ) <br /> 01 f ) 02 ( ) 03 <br /> f ) Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( ] 02 ( ) 03 <br /> ( ) <br /> 01 f ) 02 ( ) 03 <br /> ( ) 01 f 1 02 ( 1 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( 1 <br /> 01 ( ) 02 ( 7 03 <br /> ( ) O1 f 7 02 ( ) 03 <br /> ( 1 <br /> 01 f ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 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 /> PEP IkIN (SIGN URE) <br /> PHONE W/AREA CODE <br /> s <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT CITY CODE COUNTY CODE <br /> CONTACT PERSON <br /> 3 <br /> PHONE W/AREA CODE <br /> OF LAST INSPECTION IN COMPLIANCE (off- <br /> PERMIT APPROVAL DATE TRANSACTION DATE <br /> ( 7 <br /> 01 YES ( ) 02 NO LOCAL PERMIT I0 # <br /> PAGE 2 <br />