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1 <br /> i <br /> lkl- / STATE ID NUMBER 00000014943002 <br /> CONTAINER CONSTRUCTION <br /> E. [ 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( ! 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: l ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: [ ) 01 DOUBLE-WALLED PIPE f ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE f 1 05 SUCTION (X) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> f 7 <br /> 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f l 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 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 /> CUPRENTLY PREVIOUSLY DELETE CASA (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 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 FIL NO ( IONATUR ) PHONE W/AREA CODE <br /> X09- X32- <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY COD! COUNTY CODE <br /> SAN IOAOUIN LOCAL HEALFH DISTRICT <br /> CONTACT PERSON ,f•.L PHONE W/AREA CODE <br /> s - r3r <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DAT! TRANSACTION DATE LOCAL PERMIT IO 0 <br /> ( ! Owl YES (n) 02 NO <br /> HSC04-070185 (10/18/851 Q8 n.c✓C� PAGE 2 <br />