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STATE ID NUMBER 00000062561001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) Ol RUBBER LINED ( ) 02 ALKYD LINING l l 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 105 GLASS LINING <br /> (X) 07 UNLINED ( 1 08 UNKNOWN ( ) 09 OTHER: <br /> F. f ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING (X) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN ( 7 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( 3 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE (,V'05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> f l O1 VISUAL fXl 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND NATER MONITORING WELLS (J(!'07 PRESSURE TEST f 009 NONE [ l 10 OTHER <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT P.EQUIRED TO COMPLETE THIS SECTION <br /> CUPPENTLY PREVIOUSLY DELETE CASK (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 01 ( 1 02 ( ) 03 <br /> ( ) 03 f 1 02 ( ) 03 <br /> ( 1 01 ( l 02 ( 1 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> f 1 <br /> 01 ( ) 02 ( ) 93 <br /> ( ) O1 ( ) 02 1 ) 03 <br /> ( 1 01 ( 1 02 1 1 03 <br /> ( ) <br /> 01 1 ) 02 t ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( 1 03 <br /> ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS M HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PER ON ILING (S1 A RE) PHONE W/AREA CODE <br /> n9 h/ -3& H/ <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY COOK <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID S <br /> f ) O1 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />