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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ) 01 RUBBER LINED ( ) 02 ALKYD LINING 03 EPDXY LINING 04 PHENOLIC LINING 05 GLASS LINING <br /> ( ) 07 UNLINED L>4- 08 UNKNOWN ( ) 09 OTHER: <br /> F. ) 01 POLYETHLENE WRAP 02 VINYL WRAPPING 03 CATHODIC PROTECTION (>0-04 UNKNOWN t l 05 NONE <br /> 06 TAR OR ASPHALT 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ) 01 DOUBLErWALLED PIPE 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESWRE 05 SUCTION 06 UNKNOWN (>4- 07 HONE <br /> B. UNDERGROUND PIPING: 01 DOUBLE-WALLED PIPE 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 04 PRESSURE 04-05 SUCTION 06 UNKNOWN 07 NONE <br /> VII LEAK DETECTION <br /> 01 VISUAL 02 STOCK INVENTORY 04 VAPOR SNIFF WELLS 05 SENSOR INSTRUMENT'­t.. <br /> ()6 GROUND WATER MONITORING WELLS 07 PRESSURE TEST Lkl 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 (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 01 02 ( 03 1 <br /> 01 02 ( 0-1 <br /> 01 02 ( 03 <br /> 01 02 ( 03 <br /> 01 02 O ®3 13 <br /> LH Ll i I I I I I <br /> 01 O02 O03iiiililliiiLi <br /> 01 02 ( ) 03 <br /> 01 O02 1 1 03 <br /> 01 O02 ( ) o:s <br /> 01 OD2 1 ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? 01 YES 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) SAN TQUIN LOCAL HEALTH DISTRICT PHONE W/APEA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> [ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPINSPECTIONIN COMPLIANCE OVAL DATE TRANSACTION DATE FOCAL PERMIT ID # <br /> 01 <br /> 1 YES 02 NO <br /> HSC04-070185 PAGE 2 <br />