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1 0 <br /> STATE ID NUMBER 00000064782001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING ( l 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP f ) 02 VINYL WRAPPING i ) 03 CATHODIC PROTECTION ( 1 04 UNKNOWN (X) 05 NONE <br /> ( ) 06 TAR OR ASPHALT [ l 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 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> f 1 01 VISUAL (X) 02 STOCK INVENTORY ( } 04 VAPOR SNIFF WELLS ( } 05 SENSOR INSTRUMENT <br /> ( 1 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( 1 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECYED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> i ) 01 ( ) 02 ( 1 03 <br /> l 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( l 03 <br /> [ 1 01 ( ) 02 ( ) 03 <br /> ( 1 01 f ) 02 1 ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> [ ) 01 ( ) 02 ( ) 03 <br /> i ) 01 ( ) 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY ANDr TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON F IN IS13NATURE-L PHONE W/AREA CODE <br /> FpR ' AL AGENCY USE ONLY <br /> ADM'NISTRATIN AGENCY ' 1 /� I ( CI JOE COUNTY CODE <br /> CONT T PEPSON IL�Id �/J�F �{r� P NE W/AREA CODE <br /> e's _H r\- a m �3,3 Y -76 .5 <br /> DATE OF LAST INSPECTION IN CCMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES ( J 02 NO <br /> HSC04-070145 (10/18/85) PAGE 2 <br />