Laserfiche WebLink
STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED 1 1 02 ALKYD LINING ( 1 03 EPDXY LINING 1 1 04 PHENOLIC LINING ( 105 GLASS LINING <br /> (' ) 07 UNLINED IACf OB UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP 1 1 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION Oer 04 UNKNOWN f l 05 NONE <br /> I ) 06 TAR OR ASPHALT 1 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 1 1 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE ( ) 05 SUCTION ( l 06 UNKNOWN ()wf 07 NONE <br /> B. UNDERGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (?(I 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> f ) 01 VISUAL 0wr 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ra r07 PRESSURE TEST ( .1 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 CASK (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 1 ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> f ) Ol ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 1 ) 03 <br /> f 101 ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 ( ) 03 —71 <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (kr02 NO <br /> THIS FORK 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 /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> San Joaquin Local Health District 1 39 <br /> CONTACT PERSON PHONE W/AREA CODE <br /> Leo Soave 209-982-1604 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO q <br /> 9-11-8fi- O1 YES ( ) OQ NO <br /> HSC04-070185 (10/18/85) M.A. #8 PAGE 2 <br /> A - <br />