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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E ( 1101 RUBBER <br /> RfJd OB LINED2 ALKYD LINING <br /> 09 OTHER3 EPDXY LINING l 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 07 UNLINED <br /> KNOWH <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION hE1 04 UNKNOWN l ) 05 NONE <br /> ( 1 06 TAR OR ASPHALT 1 ) 09 OTHER: <br /> VI PIPING <br /> A ABOVEGROUND <br /> APPROPRIATE BOX(ES) ( ( 0104 PRESSURELEO 11PE 02 05 SUCTION CONCRETE-LINED W 071 NONE GRAVITY <br /> B. UIOERGROUO) PIPING ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH t 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 7 04 PRESSURE ( 1 05 SUCTION U4-06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS 1 1 05 SENSOR INSTRUMENT <br /> t 1 06 GPOUIN) WATER MONITORING WELLS t 1 07 PRESSURE TEST (XF 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO SV-F YOU ARE NOT REQU:REO TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# IIF KNOWN) CHEMICAL IDN NOT USE COMMERCIAL NAME) <br /> STORED STORED _ <br /> ( ) 01 l ) 02 1 ) 03 <br /> ( 1 01 ( 1 02 ( 1 03 <br /> ( ) O1 f 102 I ) 03 <br /> I 7 <br /> 01 l ) 02 ( ) 03 <br /> f ) Ol ( 1 02 f 1 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> f ) 01 ( ) 02 1 ) 03 <br /> 1 I Ol ( ) 02 ( ) 03 <br /> ( 1 Ol 1 ) 02 ( ) 03 <br /> 1 ) Ol 1 1 02 ( ) 03 <br /> IS CO!fTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES 17101 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF NY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMI/IISTPATING AGENCY CITY CODE COUNTY CODE <br /> San Joaquin Local Health District 1 39 <br /> CONTACT PERSON PHONE W/AREA CODE <br /> Leon Adamson 209-944-3738 <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> g ls"fSG ( ) 01 YES f 1 02 NO <br /> HSC04-070185 9& �r - PAGE 2 <br />