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• • STATE ID NUMBER 00000038891002 CONTAINER CONSTRUCTION E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING f ) 05 GLASS LINING (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: Ol POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION f 1 04 UNKNOWN ( ) 05 NONE (X) 06 TAR OR ASPHALT ( 7 09 OTHER: VI PIPING A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07.NONE B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE f 1 05 SUCTION ( 1 06 UNKNOWN ( l 07 NONE VII LEAK DETECTION 'S ( 0106VISUAL GROUNDIX) 02 STOCK WATER MONITORINGNWELLS 04 007 PRESSURESNIFF TESTWELLS( )f 09 NONE 10 05 SENSOR INSTRUMENT 10 OTHER: VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS IP YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION CURRENTLY PREVIOUSLY DELETE OAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) STORED STORED f 1 01 ( 1 02 ( l 03 ( ) 01 l ) 02 l ) 03 l ) Oi ( ) 02 z ( 1 03 ( ) O1 ( ) 02 ( ) 03 f ) 01 ( ) 02 ( ) 03 ( 1 O1 ( ) 02 ( ) 03 l ) 01 ( 1 02 f ) 03 ( l 01 ( 1 02 ( ) 03 (. ) Ol ( 7 02 ( 7 03 ( ) Ol f ) 02 ( ] 03 CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) O1 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. PER ON IL ONATURE) PHONE W/AREA CODE FOR LOCAL AGENCY USE ONLY ADMINISTRATING GENCY CITY COOK COUNTY CODE At VadalgAt6rW_ PH E W/A EA CODE CO NTA{��_P E R SON,l. DATE OF LAST I/NSPPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # ( ) 01 YES ( ) 02 NO PAGE 2 HSC04-070185 (10/18/85)