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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYO LINING ( l 03 EPDXY LINING t ) 04 PHENOLIC LINING l ) 05 GLASS LINING <br /> ( ) 07 UNLINED (x"08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING t ) 03 CATHODIC PROTECTION (_x4--04 UNKNOWN ( D 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING g <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE�-WALLED PIPE ( D 02 CONCRETE-LINED TRENCH t ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRES�URE ( ) 05 SUCTION 06 UNKNOWN t ) 07 NONE <br /> t <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH 9W 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE 05 SUCTION ( ) 06 UNKNOWN t ) 07 NONE <br /> VII LEAK DETECTION <br /> t D 01 VISUAL ) 02 STOCK INVENTORY t D 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUME <br /> ( ) 06 GROUND WATER MONITORING WELLS 07 PRESSURE TEST ( ) 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 REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) <br /> 01 ( ) 02 ( l 03 <br /> ( ) 01 t l 02 ( ) 03 1-1- <br /> ( ) 01 ( ) 02 ( ) 03 I II <br /> 01 02 03 <br /> ( l01 c ) 02 O03 LlIIIiIIIII <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( l 01 t ) 02 ( ) 03 <br /> ( ) 01 t ) 02 ( ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEOGEP IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) (PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY SAN JOAQLIItV LOCAL HEALTH DISTRICT CITY CODE <br /> COUNTY CODE <br /> CONTACT PSPSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> t ) 01 YES f D 02 NO <br /> HSC04-070185 PAGE 2 <br />