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STATE ID NUMBER 00000014943016 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING f 1 03 EPDXY LINING [ ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X1 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN f ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING! ( ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( l 05 SUCTION (l Cl 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 102 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION 1 ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> [ l 01 VISUAL UG 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND"WER MONITORING WELLS Sel 07 PRESSURE TEST A=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 /> CURRENTLY PREVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> I 1 01 ( ) 02 ( ) 03 <br /> ! ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> f ) O1 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( 1 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 FILING (SIGN TUWE) PHONE W/AREA COD! <br /> 44 <br /> 209-FOR LOCAL LOCAL AGE CY USE ONLY <br /> ADMINISTRATING AGENCY �T T CITY CODE COUNTY CODE <br /> SAN JOpQUIN LOCAL HEALTH DISTRICT <br /> 3 <br /> CONTACT,P ;ON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> f ) 01 YES f ) 02 NO <br /> NSC04-070185 (10/18/85) MA, PAGE 2 <br />