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CONTAINER CONSTRUCTION STATE ID NUMBER <br /> • <br /> E. f 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> [ ) 07 UNLINED IWGS UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING 1 ) 03 CATHODIC PROTECTION 00-04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 7 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOM ES) L4 04 PRESSURE 04 05 SUCTION f ) 06 UNKNOWN ( ) 07 NONE ii <br /> S. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE 1 ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE t> ) 05 SUCTION ( ) 06 UNKNOWN f ) 07 NONE <br /> VII -LEAK DETECTION <br /> ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f 1 05 SENSOR INSTRUMENT <br /> f ) 06 GROUND WATER MONITORING WELLS l ) 07 PRESSURE TEST OCf 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 (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> (M 01 ( ) 02 ( ) 03 Q �Ke./ at• <br /> ( 1 01 l ) 02 f 1 03 <br /> f ) Ol ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( ) O1 f ) 02 ( ) 03 <br /> f ) 01. ( ) 02 ( ) 03 <br /> ( 1 01 f ) 02 ( ) 03 <br /> l ) 01 ( l 02 ( ) 03 <br /> f 7 01 ( ) 02 ( ) 03 <br /> f ) 01 [ ) 02 ( ) 03 <br /> IS CO!ITAINER LOCATED ON AN AGRICULTURAL FARM? f 1 01 YES f.14-02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND. TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) PHON! W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> AOMINISTPATING AGENCY CITY CODE COUNTY CODE <br /> San Joaquin Local Health District 39 <br /> T CT PERSON PHONE W/AREA CODE <br /> Ts Dyer 209-838-3575 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 9-4-86 ( ) 01 YES f ) 02 NO <br /> HSC04-070185 <br /> PAGE 2 <br />