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�� '100-"STATE ID NUMBER 00000052900001 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING ( ) 07 UNLINED (X) 08 UNKNOWN ( 1 09 OTHER: F. ( 7 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (XI 04 UNKNOWN ( ) 05 NONE f ) 06 TAR OR ASPHALT ( J 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( ] 07 NONE VII LEAK DETECTION (X) O1 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT ( ) 06 GROUND WATER MONITORING WELLS ( 7 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IP YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) STOPED STORED ( 1 01 ( ) 02 ( ) 03 f 1 01 ( ) 02 ( ) 03 ( ) 01 f l 02 ( 1 03 ( ) 01 f ] 02 ( ) 03 [ l 01 l l 02 ( 1 03 I 7 01 ( 1 02 ( ) 03 ( l al l l 02 ( ) 03 ( 1 01 l ) 02 f ) 03 ( 1 01 ( ) 02 ( ) 03 ( ) 01 ( 1 02 l 1 03 • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINERLOCATED ONAH AGRICULTURAL FARM° ( ) 01 X) THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. PERSON FILING (SIGNATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ACITY CODE COUNTY CODE ADMINISTRATING AGENCY CONTACT PERSON PHONE W/AREA CODE DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) O1 YES ( ) 02 NO PAGE HSC04-070185 (10/18/85) `ol \/