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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E l 1(01 RUBBER LINEDfYI 02 ALKYO <br /> LINING <br /> 09 ( 1 03 EPDXY LINING l ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> 07 <br /> NED <br /> F ( )(01 POLYETHLENE WRAP <br /> f())02 VINYL <br /> OTHERWRAPPING ( ) 03 CATHODIC PROTECTION <br /> 06TAR ORVRI 04 UNKNOWN ( 7 05 NONE <br /> VI PIPING <br /> A. ABOVEGROUND PIPING f 1 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( 7 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (7O 05 SUCTION ( 7 06 UNKNOWN ( ) 07 NONE <br /> B. UtIDERGROVnD PIPING ( ) 01 DOUBLE-WALLED PIPE ( 7 02 CONCRETE-LINED TRENCH t ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX ES) ( 1 04 PRESSURE (1tI 05 SUCTION ( ) 06 UNKNOWN ( 7 07 NONE <br /> VII LEAK DETECTION <br /> 05 <br /> ( ; ) 06 GROU14D WATER MONITOR NG WELLS ( 04(1fY 07VPRESSUREFTESTLLS )f 09 NONEEN(OR INSTRUMENT <br /> 0OTHER; <br /> VIII ICCOMPOSITION MATERIALSREDNDERGROUND CONTAINERS <br /> YOU CHECKEDYES DIV-F YOU nRED rDCOMPLETEs SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASR (IF KNOWN) <br /> CHEMICAL 100 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> U!1 D1 ( ) 02 ( ) 03 Q �/�Q/` LiGC/ <br /> l 1 01 [ ) 02 ( ) 03 <br /> ( I <br /> 01 ( 1 02 ( ) 03 <br /> l ) 01 t ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 l 103 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> ( 7 01 l ) 02 ( ) 03 <br /> l ) <br /> 01 ( 7 02 l ) 03 <br /> f ) 01 ( ) 02 [ ) 03 <br /> f 101 l ) 02 ( 1 03 <br /> i <br /> IS CO!n'AINER LOCATED ON AN AGRICULTURAL FARM? f 7 01 YES l3A 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 /> PHONE W/AREA CODE <br /> PERSON FILING (SIGNATUEE) <br /> FOR LOCAL AGENCY USE ONLY <br /> CITY CODE COUNTY CODE <br /> ADMINISTRATING AGENCY 39 <br /> San Joaquin Local Health District <br /> PHONE W/AREA CODE <br /> CONTACT PERSON 209-982-1604 <br /> Leo Soave <br /> DALE OF LAST NSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID A <br /> �J ( ) 01 YES ( ) 02 NO <br /> M.A. #8 PAGE 2 <br /> HSC04-070185 <br />