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STATE ID NUMBER 00000065875001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> i ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER= <br /> F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER- <br /> VI PIPING <br /> A. ABOVEGROUND PIPING- ( ) 01 DOUBLE—WALLED PIPE i 1 02 CONCRETE—LINED TRENCH f 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN _J�L"7 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE—WALLED PIPE ( ) 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) _L)_<[_04 PRESSURE ( ) 05 SUCTION �kY'06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL _L'"2 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ) 05 SENSOR INSTRUMENT <br /> f 1 06 GROUND WATER MONITORING WELLS ( 7 PRESSURE TEST 09 NONE } ,10 OTHER: L-. A a �� 0,e_�,e c de <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 CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( J 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 1 11 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> i I <br /> 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> i ) <br /> 01 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGEs IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> San Joaquin Local Health District 1 <br /> J <br /> CONTACT PERSON PHONE W/AREA CODE <br /> Norman Desmarais 209-944-3737 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL. DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> c3-25-86 ( ) 01 YES ( ) 02 No <br /> M.A. #5 or removal <br /> HSC04-070185 (08/29/86) PAGE 2 <br />