Laserfiche WebLink
STATE ID NUMBER 00000013101002 <br /> CONTAINER CONSTRUCTION <br /> E <br /> RUBBER LINED ( ) 02 ALKYD LINING ( ] 03 EPDXY LINING f 1 04 PHENOLIC LINING f 3 05 GLASS LINING <br /> 07 UNLINED ( l 08 UNKNOWN f 1 09 OTHER: <br /> POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN f ) 05 NONE <br /> 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f l 91 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 7 04 PRESSURE 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> 1 ) 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS (X) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> :F YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVICUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( 1 <br /> 01 ( ) 02 [ 1 03 O. <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> [ 1 01 ( ) 02 ( 1 03 <br /> ( l <br /> 01 ( ) 02 ( ) 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> f 1 O1 ( ) 02 ( 1 03 <br /> f 1 Ol ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> t 1 Ol f ) 02 ( ) 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 FORM HAS BEEN COMPLETED UNTH PENALTY OF PERJr AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) /� PHONE W/AWEA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINIS_ TRATIN AGENCY CITY CODE COUNTY COOK <br /> CONTAGC T /_PEYRSON C ' � 3XON[ P.,C� <br /> DATE OF /L`"ASSt(T'_\IINSSC <br /> lPPECTIONN IN)VOOMPLIANCE PERMIT APPROVAL DATE /('TRANSACTION DATE o` (YLOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> KSC04-070185 (10/18/85) PAGE 2 <br />