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STATE ID NUMBER 00000058690006 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER* <br /> F. ( l 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 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 LA ' 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APFROPP,IATE BOX(ES) 4. ) 04 PRESSURE W" 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> f l 06 GROUND WATER MONITORING WELLS U() 07 PRESSURE TEST ( ) 09 NONE (X) 10 OTHER: Line Leak Detectors <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT PEGUIPED TO COMPLETE THIS SECTION <br /> CUPRENTLY PCEVICUSLY DELETE CASft (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( ) 01 ( ) 02 ( l 03 <br /> ( ) 01 ( ) 02 f ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( l 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 f ) 02 ( ) 03 <br /> ( l <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( l 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( l 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 <br /> • 0 <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTPATING AGENCY CITY CODE COUNTY CODE <br /> San Joaquin Local Health District 39 <br /> CONTACT PERSON PHONE W/AREA CODE <br /> Bill Harmening 209-944-4078 <br /> DATE OF LAST INSPECTION IN COMPLIANCEPERMIT .APPROVAL DATE TRANSACTION DATE LOCAL PERMIT 10 # <br /> 7-29-86 ( ) 01 YES ( ) 02 NO <br /> M.A. #5 <br /> HSC04-070185 (10/18/85) PAGE 2 <br />