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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. t ) 01 RUBBER LINED ( ) 02 ALKYD LINING 03 EPDXY LINING 04 PHENOLIC LINING 05 GLASS LINING <br /> ( ) 07 UNLINED (i-,�T8 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 N-4-07 NONE <br /> B. UNDERGROUND PIPING: 01 DOUBLE WALLED PIPE 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 04 PRESSURE P<f OS SUCTION 06 UNKNOWN 07 NONE <br /> VII LEAK DETECTION <br /> 01 VISUAL 0-Y 02 STOCK INVENTORY 04 VAPOR SNIFF WELLS 05 SENSOR INSTRUMENT <br /> - <br /> 06 GROUND WATER MONITORING WELLS Ocl-07 PRESSURE TEST 09 NONE 10 OTHER-'-_ -- <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS _ <br /> IFYOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 01 02 03 <br /> O 01 O 02 t 1 03 <br /> 01 02 03 H I I 1M I I I <br /> 01 02 1 03 <br /> 01 02 O 03 1 1 LLLLI i I I I I I <br /> 01 02 ( 13 1 <br /> 01 02 ( 03 <br /> 01 02 ( 1 ®3liillllllllil <br /> 01 02 ( ) 03 <br /> 01 1102 ( 031111111111111 <br /> 25 CONTAINER LOCATED ON AN AGRICULTURAL FARM? 01 YES 0<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/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> [ADMINISTRATING AGENCY SAN JOAQUIN LOCAL HEALTH DISTRICT CITY CODE COVNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE FOCAL PERMIT 10 # <br /> DATE OF LAST INSPECTIOTNIN( COMPLIANCE PERMIT APPROVAL DATE ]TRANSACTION DATE <br /> 01 YES 02 NO <br /> HSC04-070185 PAGE 2 <br />