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& 0 STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 01 RUBBER LINED 02 ALKYD LINING t l 03 EPDXY LINING 04 PHENOLIC LIMING ( ) 05 GLASS LINING <br /> 07 UNLINED 0-0 08 UNKNOWN 09 OTHER: <br /> F. 01 POLYETHLENE WRAP 02 VINYL WRAPPING 03 CATHODIC PROTECTION 04 UNKNOWN 05 NONE <br /> 06 TAR OR ASPHALT 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 01 DOUBLE-WALLED PIPE 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 04 PRESWRE 05 SUCTION 06 UNKNOWN (>d 07 NONE <br /> B. UNDERGROUND PIPING: 01 DOUBLE-WALLED PIPE 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 04 PRESSURE (V 05 SUCTION 06 UNKNOWN 07 NONE <br /> VII LEAK DETECTION <br /> 01VISUAL 02 STOCK INVENTORY 04 VAPOR SNIFF WELLS 05 SENSOR INSTRUMENT,--.--,,. <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 (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 01 O 02 O 13 1 1 1 1 <br /> 01 O 02 03 1 1 1 1 <br /> 01 02 03H_ Hllll I Jill <br /> 01 02 03 1 1 1_1 <br /> 1 1 <br /> 01 020031 1 LLLLl i I I I 1 1 <br /> O 01 02 O03 LII <br /> 01 02 03 <br /> O 01 O 02 ( ) 03 <br /> 01 O02 O03 03 <br /> 01 02 ( ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? 1 01 YES 0-4-02 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) PHONE W/APEA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> (ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> CONTACT PERSON PHONE W/AREA CODE <br /> —] <br /> DATE OF LAST INSPECTION IN COMPLIANCE IPERMIT APPROVAL DATE ]'TRANSACTION DATE LOCAL PERMIT ID # <br /> I ( ) 01 YES 02 NO <br /> HSC04-070185 to 'be- mmoi/ed PAGE 2 <br />