Laserfiche WebLink
I a <br /> STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. I 1 01 RUBBER LINED ( 1 02 ALKYD LINING ( 1 03 EPDXY LINING 1 1 04 PHENOLIC�-_LINING l 1 05 GLASS LINING <br /> 1: ) 07 UNLINED OB UNKNOWN ( 1 09 OTHER: <br /> F. I ) 01 POLYETHLENE WRAP 1 ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 4 UNKNOWN 1 1 05 NONE <br /> 1 ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE t 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) T 1 04 PRESSURE ( ) 05 SUCTION f-kl-06 UNKNOWN 1 ) 07 NONE <br /> " B. UNDERGROUND PIPING: t ) 01 DOUBLE-WALLED P PE t ) 02 CONCRETE-LINED TRENCH t ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE W-05 SUCTION l 1 06 UNKNOWN 1 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL 1 1 02 STOCK INVENTORY 1 ) 04 VAPOR SNIFF WELLS _2!;f05 SENSOR INSTRUMENT <br /> d_A6 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( :1 09 HONE 1 1 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECF,ED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASE IIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> Ol 1 1 02 ( ) 03 6 <br /> ( ) Ol t 1 02 ( ) 03 <br /> ( 1 O1 t 1 02 ( ) 03 <br /> f 1 Ol ( 1 02 ( ) 03 <br /> l 101 l 102 ( ) 03 <br /> ( 1 Ol ( 1 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( 1 03 <br /> l 101 1 102 f 103 <br /> ( ) 01 f ) 02 ( ) 03 <br /> f ) 01 ( 1 02 ( ) 03 <br /> • CHECK STATE BOARD CHEMICAL CODE L13TING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? 1 1 01 YES 0<f 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 ISIONATURE) PHONE W/ARCA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATINO AGENCY CITY CODE COUNTY CODE <br /> San Joaquin Local Health District 1 39 <br /> C TACT ITOp PINE W94fi-1423 <br /> °hoax NT c(lo I son <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID R <br /> 7-28-86 . I ) 01 YCS I ) 02 NO <br /> M.A. #2 <br /> MSC04-070105 (10/18/05) PAGE 2 <br /> l _ _ <br />