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STATE ID NUMBER 00000014475003 CONTAINER CONSTRUCTION E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING l ) 05 GLASS LINING f ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER= F. f ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN [ 1 05 NONE l ) 06 TAR OR ASPHALT ( 1 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE B. UNDERGROUND PIPING f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN f ) 07 NONE VII LEAK DETECTION ( 1 01 VISUAL ( ) 02 STOCK INVENTORY l ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT ( 1 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST (X) 09 NONE [ 1 10 OTHER= VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS If YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STORED ( ) 01 ( ) 02 ( 1 03 l 1 O1 ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 ( l Ol ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 f ) 01 ( ) 02 ( ) 03 f 1 O1 ( ) 02 ( ) 03 f 1 Ol ( ) 02 ( ) 03 ( ) 01 ( ) 02 ( ) 03 f l_02 ( ) 02 ( ) 03 * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO 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 ADMINISTRATING AGENCY CITY CODE COUNTY COOK CONTACT PERSON PHONE W/AREA COOK DATE OF LAST INSPECTION IN COMPLIANCC PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # f ) Ol YES f ) 02 NO HSC04-070185 (10/18/85) .PAGE 2 )