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STATE ID NUMBER 00000065877001 <br />CONTAINER CONSTRUCTION <br />iE. 01 RUBBER LINED 02 ALKYO LINING 03 EPDXY LINING 04 PHENOLIC LINING 05 GLASS LINING <br />07 UNLINED (X) 08 UNKNOWN 09 OTHER: <br />01 POLYETHLENE WRAP 02 VINYL WRAPPING 03 CATHODIC PROTECTION (X) 04 UNKNOWN 05 NONE <br />i. TAR OR ASPHALT i. • OTHER: <br />VI PIPING <br />ABOVE GROUND PIPING: ( ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />..a{:.a :# 04 PRESSURE 05 SUCTIONi. UNKNOWN07 NONE <br />li <br />B. UNDERGROUND PIPING: t ) 01 DOUBLE -WALLED PIPE 02 CONCRETE -LINED TRENCH 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE j_VJ5 SUCTION jZe_06 UNKNOWN 07 NONE <br />[ LEAK DETECTION <br />01 VISUAL jj%,02 STOCK INVENTORY 04 VAPOR SNIFF WELLS 05 SENSOR INSTRUMENT <br />06 GROUND WATER MONITORING WELLS (ld 07 PRESSURE TEST (X) 09 NONE 10 OTHER: <br />VIII CHEMICAL COMPOSITION OF MATERIALS STO.R D -IN UNDERGROUND CONTAINERS <br />IF YOU CHECKED YES TO IV -F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br />CURRENTLY <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (OO NOT USE COMMERCIAL NAME) <br />( ) O1 <br />( ) 02 <br />t ) 03 <br />t l 01 <br />( ) 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />t ) 03 <br />t ) 01 <br />( ) 02 <br />t ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />t ) 01 <br />t ) 02 <br />( ) 03 <br />t ) 01 <br />( ) 02 <br />t ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />* CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br />IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 <br />PHIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY A ► TO THE BEST OF MY KNOWLEDGEP IS TRUE AND CORRECT. <br />PERSON FILING (SIGNATURE) =PHONE W/AREA CODE <br />FOR LOCAL AGENCY USE ONLY <br />ADMINISTRATING AGENCY CITY CODE CQUNTY CODE <br />San Joaquin Local Health District 39 <br />CONTACT PERSON PHONE W/AREA CODE <br />Norman Desmarais 209-944-3737 <br />DATE OF LAST INSPECTIONIN COMPLIANCE JPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br />8-27-86 1 ( ) 01 YES ( ) 02 NO <br />HSC04-070185 (08/29/86) M. A. #5 <br />PAGE 2 <br />