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r� <br /> STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED t ) 02 ALKYD LINING t 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING t ) 05 GLASS LINING <br /> f ) 07 UNLINED �8 UNKNOWN ( 1 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING 1 ) 03 CATHODIC PROTECTION (kf 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT [ 1 09 OTHER: <br /> VI PIPING <br /> A.' ABOVEGROUfD PIPING: 1 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) { ) 04 PRESSURE i ) OS SUCTION L�d_06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE { ) 02 CONCRETE-LINED TRENCH [ 1 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(E5) ( 1 04 PRESSURE 00 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (Y1 02 STOCK INVENTORY 1 ) 04 VAPOR SNIFF WELLS i 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROL940 WATER MONITORING WELLS (XI 07 PRESSURE TEST ( ) 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 /> L <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL 100 NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( ) O1 ( ) 02 ( ) 03 <br /> [ 1 01 ( ) 02 ( ) 03 pp <br /> { l Oi ( l 02 ( ) 03 LI I I I I I <br /> ( ) Ol [ ) 02 ( ) 03 <br /> { ) al [ ) 02 ( 103t 1 1 ) 1 1 1 1 1 1 1 1 <br /> ( fol I IC2 ( ) 03 � <br /> t 1 <br /> 01 I ) 02 ( ) 03 <br /> ( 1 01 [ 1 02 d ) 03 <br /> ( ) <br /> 01 ( ) 02 f ) 03 <br /> d 1 01 I ) 02 ( 1 03 <br /> IS CO'fTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES _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) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTPATING AGENCY CITY CODE COUNTY CODE <br /> San Joaquin Local Health District 39 <br /> CONTACT PEF.SON PHONE W/AREA CODE <br /> Jim Salamony 209-944-2177 <br /> DATE OF LAST INSPECTION �IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID 4 <br /> 8-25-86 c ) of YES <br /> ( ) 02 NO <br /> Isca4-0701e5 <br /> M.A. <br /> A. #8 PAGE 2 <br />