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STATE ID NUMBER 00000058690003 <br /> CONTAINER CONSTRUCTION <br /> E. ( I 01 RUEBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP [ ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAP. OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( l 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER. MONITORING WELLS 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECNEO -i ES TO IV-F YOU APE NOT PEQUIPED TO COMPLETE THIS SECTION <br /> CURRENTLY PPEVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STC--EO STCFED <br /> (X) 01 ( ) 02 ( 1 03 f SOLVENTS <br /> ( ) 01 ( ) 02 ( l 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( l 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> f ) <br /> 01 ( 1 02 ( l 03 <br /> ( 1 <br /> 01 ( l 02 ( 1 03 <br /> ( ) <br /> 01 ( l 02 ( ) 03 <br /> [ 1 <br /> 01 ( 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 /> F-cRSON FILIN3 (SIGNATURE) PHONE W%APEA CODE <br /> 0 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTPAT:NG AGENCY CITY CODE COUNTY CODE <br /> San Joaquin Local Health District 39 <br /> CCNTA.CT PE=SON PHONE WiARE.A CODE <br /> Bill H 209-944-4078 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID .Y <br /> 7-29-86 ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) " 0� �*' PAGE 2 <br />