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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING t D 03 EPDXY LINING t 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (_'S)-08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( D 03 CATHODIC PROTECTION ( UNKNOWN ( ) 05 NONE <br /> [ D 06 TAR OR ASPHALT ( D 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: t ) 01 DOUBLErWALLED PIPE t D 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRE$ RE ( ) 05 SUCTION t ) 06 UNKNOWN 07 NONE <br /> B. UNDERGROUND PIPING- ( D 01 DOUBLE{{-WALLED PIPE ( D 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ! ') 04 PRESSURE 05 SUCTION t ) 06 UNKNOWN ( D 07 NONE <br /> VII LEAK DETECTION <br /> ( i 01 VISUAL (,V--ft STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT—*, <br /> ( 3 06 GROUND WATER MONITORING WELLS 7 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER <br /> _t <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS _ <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASA (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( D01 ( 02 ( ) 031111111111111 - <br /> ( ) 01 ( ) 02 ( ) 03 I <br /> ( D01 ( D02 ( ) 031J I I LJ I I 1 I I <br /> 01 t ) ®2 () 031i1llllllilll <br /> ( ) 01 ( ) 02 ( ) 03 �L <br /> d ) 01 ( J02 ( ) 031 111 1 1 111 1 1 1 1 <br /> tD01 ( 02 () 03 IIIILII 11�I�i <br /> ! ) 01 ( ) 02 ( ) 03 ! I <br /> ( D01 () 02 O0311Illllllllll <br /> ( D01 ( ) 02 ( ) 031111111111111 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (>r62 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 (SIGNATURE) TONE <br /> W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY ­SAN JOAQUIN LOCAL HEALTH DISTRICT CITY CODE COUNTY CODE <br /> CONTACT PEP.SON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( D 02 NO <br /> HSC04-070185 PAGE 2 <br /> iI <br />