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0 p 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 (),)- 08 UNKNOWN 09 OTHER: <br /> F. 01 POLYETHLENE WRAP 02 VINYL WRAPPING 03 CATHODIC PROTECTION (>4- 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 PRES RE 05 SUCTION 06 UNKNOWN Q'k4 07 NONE <br /> B. UNDERGROUND PIPING: t D 01 DOUBLE-WALLED Z;PE ( ) 02 CONCRETE-LINED TRENCH 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 04 PRESSURE SUCTION UCTION 06 UNKNOWN 07 NONE <br /> VII LEAK DETECTION <br /> 01 VISUAL (,-%1'02 STOCK INVENTORY 04 VAPOR SNIFF WELLS 05 SENSOR INSTRUMENT­A,_ <br /> 06 GROUND WATER MONITORING WELLS LA--Y 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 PEqUIFEO TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASU (IF KNCWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 01 O02 )23 ULLi-LU I I I I I <br /> 01 1102 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> 01 02 03 Lj H I 1_1 .1 I I I I I <br /> 01 O0203 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> 01 02 03 1 [_LLLI i I I I I I <br /> 01-- --)_02 03 I I I I I I 1 L i I I <br /> 01 t l 02 t ) 03 <br /> 01 02 ) 03 <br /> 01 O02 O031111Illlllill <br /> 01 02 ) 03 <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? 01 YES 0<7'02 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/APEA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> (ADMINISTRATING AGENCYSAN JOAQUIN LOCAL HEALTH DISTRICT CITY CODE COUNTY CODE <br /> .. ............... <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE ];ERMIT APPROVAL DATE ]TRANSACTION DATE FOCAL PERMIT 10 # <br /> 01 YES 02 NO <br /> HSC04-07018.5 PAGE 2 <br />