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•___• —.. <br /> STATE ID NUMBER 00000014943027 <br /> CONTAINER CONSTRUCTION <br /> E. f 7 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING f l 04 PHENOLIC LINING f l 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. f l 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( ] 04 UNKNOWN f l 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING= ( 7 01 DOUBLE-WALLED PIPE f l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> S. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( 106 UNKNOWN l ) 07 NONE <br /> VII LEAK DETECTION <br /> E07:VISUAL ( 102 8TOCK INVENTORY ( 7 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> 6 GROUND WATER MONITORING WELLS l 1 07 PRESSURE TEST fXl 09 NONE l ) 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU AVE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( l of q(l oz ( 7 03 u/"4e S t„c.lud" solvew�s <br /> ( 7 0l f)() 02 ( 7 a3 ivkd e 5o ✓ <br /> f ) O1 ( 7 02 ( ) 03 <br /> f 7 of ( ) 02 ( ) 03 <br /> l l 01 f ) 02 ( l 03 <br /> f ) 01 ( ) 02 ( 103 <br /> f ) 01 ( ) 02 ( 1 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> l ) <br /> 01 f ) 02 f ) 03 <br /> f ) O1 f l 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 FILING !SIGNATURE) PHONE W/AREA CODE B <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r�e <br /> CONTACT PERSON <br /> - '. - PRONE W/ARlA COD! <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 1 1 01 YES ,,( 11/ 02 NO /�// <br /> HSC04-070185 (10/18/85) / !� lV GG ✓c �/ ` �M�yy�� PAGE 2 <br />