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STATE ID NUMBER 00000037907008 <br /> CONTAINER CONSTRUCTION <br /> E. [ l 01 RUBBER LINED [ ) 02 ALKYD LINING [ ) 03 EPDXY LINING i 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( l 08 UNKNOWN ( ) 09 OTHER. <br /> F. [ ) 01 POLYETHLENE WRAP [ ) 02 VINYL WRAPPING [ l 03 CATHODIC PROTECTION (X) 04 UNKNOWN [ ) 05 NONE <br /> ( ) 06 TAR CR ASPHALT E l 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUNO PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> [CHECK APPROPRIATE BOX(ES) €X1 04 PRESSURE [ ) 05 SUCTION ( l 06 UNKNOWN ( l 07 NONE <br /> VII LEAK DETECTION <br /> f ) 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS t ) 05 SENSOR INSTRUMENT <br /> f ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST { ) 09 NOME ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT PE4UIPED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNCWN) CHEMICAL SDO NOT USE COMMERCIAL NAME ) <br /> STOPED STORED <br /> ( ) 01 ( 1 02 ( l 03 <br /> ( 1 OI ( 1 02 ( ) 03 <br /> { 1 01 4 ) 02 ( ) 03 <br /> ( i 01 [ l 02 f ) 03 <br /> ( i 01 ( i 02 f l 03 <br /> ( 101 E ) 02 f 1 03 <br /> f ) 01 ( l 02 ( ) 03 <br /> ( l 01 ( ) 02 ( ) 03 <br /> [ l 01 ( ) 02 { ) 03 <br /> [ l 01 [ ) 02 ( l 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? E 7 01 YES (X) 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/APER CODE <br /> A <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY COOK <br /> CONTACT PERSON PHONE W/AREA CODE <br /> CATE OF LAST INSPECTION IN COMPLIANCE PERPIIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> t ) 01 YES I ) 02 NO <br /> HSCu4-070185 (10/18/85) PAGE 2 <br /> M e <br />