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0 STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( 01 RUBBER LINED ( ) 02 ALKYD LINING 03 EPDXY LINING 04 PHENOLIC LIMING 05 GLASS LINING <br /> 07 UNLINED (NY 08 UNKNOWN 09 OTHER: <br /> F. ( 01 POLYETHLENE WRAP 02 VINYL WRAPPING 03 CATHODIC PROTECTION Or)" 04 UNKNOWN 05 NONE <br /> 06 TAR OR ASPHALT 09 OTHER* <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: 01 DOUBLET-WALLED PIPE 02 CONCRETE-LINED TRENCH 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 04 PRESORE 05 SUCTION 06 UNKNOWN 0d 07 NONE <br /> - 11 <br /> B. UNDERGROUND PIPING: 1 01 DOUBLE WALLED PIPE 02 CONCRETE-LINED TRENCH 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 04 PRESSURE Cxr 05 SUCTION 06 UNKNOWN 07 NONE <br /> VII LEAK DETECTION <br /> 01 VISUAL 02 STOCK INVENTORY 04 VAPOR SNIFF WELLS 05 SENSOR INSTRUMENT---*,,_ <br /> 06 GROUND WATER MONITORING WELLS 07 PRESSURE TEST (>6 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 REWIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASU (IF KNCWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 01 02 03 <br /> 01 02 03 <br /> 01 02 0 3 II_j I I j I I I I I <br /> 01 ( 02 03 <br /> 01 ( 02 03 <br /> -H LH Ll <br /> 01 ( 02 03 I_L_J_J_La H I I I I <br /> 01 ( 02 03 <br /> 01 ( 02 03 <br /> 01 O02 1 ) <br /> O 01 O 02 O 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? 01 YES (kf 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, 15 TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> IADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE --[;;;MIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 01 YES 02 NO <br /> HSC04-070185 PAGE 2 <br />