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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( D 02 ALKYD LINING t ) 03 EPDXY LINING t ) 04 PHENOLIC LINING t D 05 GLASS LINING <br /> ( ) 07 UNLINED 00 08 UNKNOWN ,( ) 09 OTHER <br /> F. ( ) 01 POLYETHLENE WRAP ( D 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION ( 04 UNKNOWN t D 05 NONE <br /> t ) 06 TAR OR ASPHALT t D 09 OTHER= <br /> VI PIPING <br /> A. ABOVEGROUND PIPING- ( l 01 DOUBLE WALLED PIPE -( ) 02 ETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( D 04 PRE RE t D 05 SUCTION t ) 06 UNKNOWN 07 NONE <br /> B. UNDERGROUND PIPING: t D 01 DOUBLEIWALLED PIPE ( ) 02 CONCRETE-L%HED TRENCH t D 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( l 04 PRESSURE ( D 05 SUCTItNt 06 UNKNOWN t ) 07 NONE <br /> VII LEAK DETECTION <br /> t l 01 VISUAL ( ) 02 STOCK INVENTORY t D 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMER <br /> t ) 06 GROUND WATER MONITORING WELLS t ) 07 PRESSURE TEST -(Xr09 NONE ( ) 10 OTHER-Z-,_, <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS - <br /> IF YOU CHECKED YES TO IV-P YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IP KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 1101 Ooz O03111111P1f111 ( <br /> t ) 01 ( ) 02 ( ) 03 <br /> t )- 01 ( ) 02 ( ) 03 <br /> ( ) 01 t ) 02 ( ) 03I I I I I <br /> t l <br /> 01 t 102 t ) 03 Ll I I I <br /> i <br /> O01 O02 ( 1031IIffIIII ! f (.� <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( ) 03 p I <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> %S CONTAINER LOCATED ON AN AGRICULTURAL FARM? t D 01 YES t.5�02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANOP TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON PILING; (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY SAN 10AQUIN LOCAL HEALTH pISTRI CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE <br /> 01 <br /> APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( D O1 YES ( D 02 NO <br /> MSC04-070185 PAGE 2 <br />