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CONTAINER CONSTRUCTION STATE ID NUMBER <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING t l 03 EPDXY LINING t J 04 PHENOLIC LINING t l 05 GLASS LINING <br /> Q!1.07 UNLINED ( ) 08 LHIK140WN ( ) 09 OTHER: <br /> F. ( l 01 POLYETHLENE WRAP [ 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER- <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLE-WALLED PIPE t J 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 041,PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN 7 NONE <br /> B. U)(DERGROU14D PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE 05 SUCTION ( ) 06 UNKNOWN ( J 07 NONE <br /> VII LEAK DETECTION <br /> VISUAL ( 2 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 105 SENSOR INSTRUMENT <br /> ( 1 06 GROUT;D WATER MONITORING WELLS 07 PRESSURE TEST ( ) 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 CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 101 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> t 101 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> t ) 01 ( ) 02 ( ) 03 <br /> ( J 01 ( ) 02 ( ) 03 <br /> t 1 01 ( ) 02 ( 1 03 <br /> IS CO`(TAIHER LOCATED ON AN AGRICULTURAL FARM? t ) 01 YES Qd,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 (SIGNATUPE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY- <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> San Joaquin Local Health District 1 39 <br /> CONTACT PEF.SON PHONE W/AREA CODE <br /> Jim Salamon 209-944-2177 <br /> DATE OF LAST INSPECTION�COMPLYIANCZ PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 9-11 -86 S ( ) 02 NO <br /> m.A. #7 <br /> HSC04-070185 PAGE 2 <br />