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0 1p STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 01 RUBBER LINED 02 ALKYD LINING 03 EPDXY LINING 04 PHENOLIC LINING 05 GLASS LINING <br /> ) 07 UNLINED UNKNOWN ( ) 09 OTHER: <br /> F. 01 POLYETHLENE WRAP 02 VINYL WRAPPING 03 CATHODIC PROTECTION G;V'04 UNKNOWN t l 05 NONE <br /> 06 TAR OR ASPHALT 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ) 01 DOUBLE'r-WALLED PIPE 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESWRE 05 SUCTION 06 UNKNOWN (� <br /> ,+ 07 NONE <br /> B. UNDERGROUND PIPING: 01 DOUBLE'WALLED PIPE 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 04 PRESSURE Q1005 SUCTION 06 UNKNOWN 07 NONE <br /> VII LEAK DETECTION <br /> 01 VISUAL V(') 02 STOCK INVENTORY 04 VAPOR SNIFF WELLS 05 SENSOR INSTRUMENT--4,,' <br /> 06 GROUND WATER MONITORING WELLS (-VY-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 CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 01 02 ( 03 <br /> 01 02 ( 03 <br /> 01 02 ( 03U_ H M-1 H I I I <br /> 01 ( ) 02 ( 03 1 1-IL-11 <br /> 1 1 ij I I I I I I I <br /> 01 O02 0? ( 03 1 1 LLLLI i I I I I I <br /> 01 ( ) 02 ( 13 <br /> 01 ( ) 02 ( 03 <br /> 01 ( ) 02 ( 103 LII Ll I I 11 I I I I I I <br /> 01 O02 02 ( 03 <br /> 01 ( ) 02 0031 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? 01 YES 0,;Y-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 /> iPERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> [ADMINISTRATING AGENCY CITY CODE E <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPWOVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 01 YES 02 NO <br /> HSC04-070185 PAGE 2 <br />