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it <br /> 0 STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 01 RUBBER LINED ) 02 ALKYO LINING 03 EPDXY LINING 04 PHENOLIC LINING 05 GLASS LINING <br /> 07 UNLINED 08 UNKNOWN 09 OTHER: <br /> F. 01 POLYETHLENE WRAP 02 VINYL WRAPPING 03 CATHODIC PROTECTION (kr04 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 PRES RE 05 SUCTION 06 UNKNOWN [�\T 07 NONE <br /> B. UNDERGROUND PIPING: 01 DOUBLE-WALLED P;PE 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 04 PRESSURE 00' 05 SUCTION 06 UNKNOWN 07 NONE <br /> VII LEAK DETECTION <br /> 01,VISUAL 02 STOCK INVENTORY 04 VAPOR SNIFF WELLS 05 SENSOR INSTRUME_N'T---4*, <br /> 6 GROUND WATER MONITORING WELLS 07 PRESSURE TEST t-V-09 NONE 10 OTHER-'_ <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS- <br /> IF YOU c*rnxso ,ES TO zv-r YOU ARE NOT "cqvznco TO numpLa`s THIS ssorzow <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNCWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED S70RED <br /> 01 02 03 <br /> 01 02 03 <br /> 01 02 03_ <br /> 01 02 0:5 <br /> 01 02 03 <br /> 01 02 03 <br /> 01 02 03 <br /> 01 02 03 <br /> 01 02 1 13 <br /> 01 02 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? 01 YES (Ar 02 NO <br /> THIS Fonn HAS BEEN CompLeTso umopn THE pswxcr, OF PERJURY AND, TO THE oEor or MY xwOwLsoas. IS Tnus AND noRnscr. <br /> FILING (SIGNATURE) I/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY sA n-JOAQUIN LOCAL HEALTH DISTRICT CITY CODE FOUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE IT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> 01 YES 02 NO <br /> � xno04-070185 PAGE 2 <br /> ' <br />