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• • STATE I0 NUMBER <br /> , CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING 1 7 03 EPDXY LINING ( l 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (K) 08 UNF.NOWN ( ) 09 OTHER: <br /> F. ( l 01 POLYETH LENE WRAP ( 7 02 VINYL WRAPPING l ) 03 CATHODIC PROTECTION (x'04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT 1 ) 09 OTHER: <br /> VI PIPING <br /> A. A80VEGROUNO PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (J(J 04' PRESSURE (\4 05 SUCTION ( ) 06 UNKNOWN f 1 07 NONE <br /> B. UIDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) [ ) 04 PRESSURE 031 05 SUCTION ( 7 06 UNKNOWN ( 7 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> 1 ) 06 GROUND WATER MONITORING WELLS f 7 07 PRESSURE TEST 0<1 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 REgUIREO TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> (No of 1 ) oz f ) 03 p ,w_'6 <br /> ( 101 l 1 02 f ) 03 <br /> ( 7 01 ( ) 02 ( ) 03 <br /> ( 101 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> f 1 01 ( ) 02 ( ) 03 <br /> ( 1 01 f ) 02 ( ) 03 <br /> f ) 01 ( 7 02 ( ) 03 <br /> ( ) 01 [ ) 02 ( ) 03 <br /> l ) 01 f 7 02 ( ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (>q-02 NO <br /> I <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 (SIGNATUEEI PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> San Joaquin Local Health District 39 <br /> CONTA T PEFSON NE W/AREA CODE <br /> Ric Dyer PHO209-838-3575 <br /> DATE OF LAST INSPECTION IN COMPLIANCC PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 9-4-86 ( ) 01 YES ( 1 02 NO <br /> ISC04-070185 <br /> PAGE 2 <br /> 0 <br />