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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED [ 1 02 ALKYD LINING 1103 EPDXY LINING f 104 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (` 08 UNKNOWN { } 04 OTHER: <br /> F. I 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION i ! 04 UNKNOWN ( 1 05 NONE <br /> I ) 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING, C l 01 DOUBLE-WALLEO PIPE f 1 02 CONCRETE-LINED TRENCH C ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI 1 ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: f 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (11 05 SUCTION ( 1 06 UNKNOWN 1 ) 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 <br /> 01 VISUAL (X ) 02 STOCK INVENTORY t l 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> [ ) 06 GROUND WATER MONITORING WELLS (x) 07 PRESSURE TEST ( 1 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> :F YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL IDO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> [ 1 <br /> 01 ( ) 02 I 1 03 <br /> { ) 01 f 1 02 ( ) 03 <br /> t 1 01 ( 1 02 ( 1 03 <br /> ( 1 01 f ) 02 ( l 03 <br /> ( ! <br /> 01 t 102 { ) 03 <br /> ( 1 01 ( 3 02 [ ! 03 <br /> [ ) 01 ( ! 02 f ) 03 <br /> I ) 01 ( l 02 f 1 03 <br /> t 1 <br /> 01 ( 1 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 KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) - 1 PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTPATIN3 AGENCY CITY CODE COUNTY CODE <br /> San Joaquin Local Health District 39 <br /> CONTACT PERSON PHONE W/AREA CODE <br /> OATE OF LAST INSPECTIONIN COMPLIANCE PERMIT APPPOVAL DATE TRANSACTION DATE LOCAL PERMIT ID 0 <br /> f I 01 YES ! 1 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br /> F <br />