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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E, ( 1 O1 RUBBER LltifO_ 1 Q2 ALKYD LINING l 1 03 EPDXY LINING ( } 04 PHENOLIC LINING ( } 05 GLASS LINING <br /> (: I Q7 UNLINED 1�1 08 Ut4KNOWN ( 1 99 OTHER <br /> F. t } O1 PflLYETHLENE WRAP02( 119022 V09 tljHERWRAPPING f 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 1 95 NONE <br /> ( 1 06 TAR OR ASPHALT <br /> r <br /> PIPING <br /> VEGROUNO PIPING; ( 1 01 DOUBLE-WALLED PIPE 1 1 92 CONCRETE-LINED TRENCH03 GRAVITY <br /> ECK APPROPRIATE BOXES) ( 1 04 PRESSURE ( ) OS SUCTION ( 1 06 UNKNOWN 1 1 07 NONE <br /> ERGROUND PIPING 01 DOUBLE-WALLED PIPE I 1 02 CONCRETE-LINED TRENCH l 1 E GRAVITY <br /> HECK APPROPRIATE BOXfES) ( 1 04 PRESSURE lr'1 95 SUCTION ( 1 06 UNKNOWN { 1 07 NONE <br /> VII LEAK DETECTION <br /> O1 NT <br /> VISUAL INVENTORYTOCK VAPOR <br /> SNIFF WELLS 05 <br /> SENSOR 10SOHE <br /> N ELLS (X) 07PRESSURETEST ( I 09 NOONTR- <br /> ( ) 06 MONITORING <br /> LS STORED UNDERGROUND CONTAINERS <br /> VIII CHEMICAL COMPOSITION QTA <br /> IF YOU CHECKED YES TOIV_FYOU REQUIRED To COMPLETE SECTION <br /> CURRENTLY PR[VIOUSLY DELETE CASE (IF KNOWN) <br /> CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 t 1 02 ( ) 03 <br /> t } 01 t 102 ( ) 03 <br /> t 1 01 t l 02 I 103LLLLLL <br /> t 1 01 t ) 02 ( ) 03 <br /> t 1 01 ! ) 02 ( ) 03 Ll I <br /> t 1 01 ( 1 02 ( ) 03 <br /> I 01 ( 1 02 ( ) 03 <br /> { 101 ( ) 02 ( 1 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> ( } 01 t 102 ( 1 03 <br /> CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? f } 01 YES (g) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, <br /> 7D THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PHONE W/AREA CODE q 7 0 <br /> PE?SON FILING (SIGNATURE ) <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 PE;SCN <br /> PERMIT APPROVAL DATE TRANSACTION DATE <br /> LOCAL PEPMIT ID 0 <br /> 04TE OF LAST INSPECTION IN COMPLIANCE <br /> } 01 YES 1 1 02 NO _ .. <br /> PAGE 2 <br /> HSC04-070185 (10/1$/851 <br /> L <br />