Laserfiche WebLink
STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 01 RUBBER LINED ( ) OZ ALKYD LINING 03 EPDXY LINING 04 PHENOLIC LINING 05 GLASS LINING <br /> ) 07 UNLINED (-YI 08 UNKNOWN ( ) 09 OTHER: <br /> F. 01 POLYETHLENE WRAP 02 VINYL WRAPPING 03 CATHODIC PROTECTION NT 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 G\-Y 07 NONE <br /> B. UNDERGROUND PIPING: 01 DOUBLE=WALLED PIPE 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 04 PRESSURE 05 SUCTION t D 06 UNKNOWN 07 NONE <br /> VII LEAK DETECTION <br /> 01 VISUAL PiO_02 STOCK INVENTORY 04 VAPOR SNIFF WELLS 05 SENSOR INSTRUMENT—*,,, <br /> 06 GROUND WATER MONITORING WELLS (XI-07 PRESSURE TEST 09 NONE 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS ._ <br /> IF YOU CHECKED YES TO IV-P YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNCWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> O 01 O 02 O 13 1 1 <br /> 01 O 02 O 03 <br /> 01 02 1 03 <br /> 01 02 03 <br /> 01 02 03 <br /> LIH Ll i I I I I I <br /> 01 02 1 03 <br /> 01 02 t 1 13 <br /> 01 02 ( ) 0311 Lj_j I I I I I I 1 1 1 <br /> 01 02 ( ) 03 1 1 <br /> 01 O02 ( 031111111111111 <br /> IS CONTAINER 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 KNOWLEDGE, IS TRUE AND CORRECT. <br /> jjPERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE SAN JOAMIN' LOCAL HEA[.TH.­..11-STR,lcT COUNTY CODE <br /> CONTACT PERSON I PHONE W/AREA CODE <br /> �ITAPPROVAL DATE 4 DATE FOCAL PERMIT 10 <br /> DATE OF LAST INSPECTION; IN COMPLIANCE <br /> 0 ol <br /> I YES 02 NO <br /> HSC04-070185 PAGE 2 <br />