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STATE ID NUMBER 00000014943005 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING f l 03 EPDXY LINING ( 1 04 PHENOLIC LINING f 1 05 GLASS LINING ( 1 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER- F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( l 03 CATHODIC PROTECTION (X) 04 UNKNOWN f l 05 NONE ( ) 06 TAR DR ASPHALT ( l 09 OTHER: VI PIPING A. ABOVEGROUND PIPING ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 3 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE f l 05 SUCTION (X) 06 UNKNOWN ( 1 07 NONE VII LEAK DETECTION l 1 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IF YOU CHECKED YES TO IV-P YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STORED STORED ( l 01 ( ) 02 ( 1 03 ( l 01 ( ) 02 ( ) 03 f 1 01 ( ) 02 ( ) 03 l ) 01 ( ) 02 ( ) 03 ( ) O1 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 f 1 01 ( ) 02 ( ) 03 ( 7 01 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( 1 01 ( ) 02 ( ) 03 ■ CHECK STATE BOARD CHEMICAL (ADE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (S ONATURE) PHONE W/AREA CODE BOJ- 83Z -9S3f ° FOR LOCAL A ENCY USE ONLY ADMINISTRATING AGENCY SAN JOAQUIN LOCAL HEALTH DISTRICT CITY CODE COUNTY CODE CONTACT PC@SON PMON! W/AREA GODS W Icy- T-3Z- 9S3S DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # 1 0 71 YES ( ) 02 NO NSC04-070185 (10/18/85) " - �m�� PAGE 2