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STATE IO }LUMBER <br /> CONTAINER CONSTRUCTION <br /> O1 RUBBER LINED ( ) 02 ALKYD LINING [ ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING S } 05 .GLASS LINING <br /> t ) 07 UNLINED (el(} 08 UNKNOWN [ ) 09 OTHER: <br /> 01 VOLYETHLENE WRAP 1 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION W) 04 UWHOWN l ) 05 NONE <br /> 1 ) 06 TAR OR ASPHALT 1 ) 09 OTHER: <br /> VI PIPING <br /> I- <br /> A. ABOVEGROUND PIPING: [ 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LIHED TRENCH t ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXfES) ( 1 04 PRESSURE ( 105 SUCTION [ 1 06 UNKNOWN (;4 07 NONE <br /> I <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE [ } 02 CONCRETE-LINED TRENCH ( ) 03 GRAYITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE ( 1 03 'SUCTION ( ) 06 UNKNOWN [ 1 07 NONE <br /> VII LEAK DETECTION <br /> 01 VISUAL (y) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS [ ) 05 SENSOR INSTRUMENT <br /> 1 06 GROUND WATER MONITORING WELLS [ ) 07 PRESSURE TEST [ ) 09 NONE ( ) 10 OTHER: <br /> JI : I CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-P YOU AVE NOT REQUIRED TO COMPLETE THIS 92CTION <br /> 1:"UPRZNTLY PREVIOUSLY DELETE CASK (IF KNOWN) GMCMTCAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> _4 ) 01 l ) 02 [ ) 03 <br /> { } Oi [ 1 02 [ ) 03 <br /> f 1 01 i ) 02 [ )'03 <br /> { f } 01 { ) 02 t ) 03 .1 <br /> Y01 ( 102 [ ) 03 Ll1 1 1 t <br /> 01 t ) 02 ( 1 03 <br /> f } Ql 1 1 02 f ) 05 1 l <br /> r 1 01 [ ) o2 ( ) 03 p <br /> r 1 01 i } 02 { 1 13 <br /> i 1 01 1 02 f I 03 — <br /> :S CONTAINER LOCATED ON AN AGRICULTURAL FARM' ( 1 01 YES 02 NO <br /> T,IS FORM :iAS }SEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF KY KNOWLEDGE. 13 TRUE AND CORRECT. <br /> +vCRSON PILTNO SSIGNATURCI PHONE M AREA CODE <br /> h LOCAL AGENCY USE N Y <br /> CITY COOK COUNTY GOD! <br /> ADM.INISTRATINO AGENCY <br /> PHONE W/ARIA CODE <br /> LONTA:;+ PERSON <br /> eT[ Of LAtT INSPECT;ON IN COMPLIANC! PERMIT APPROVAL DATE TRANSACTION DATE LOCAL P11RM�7 ID R <br /> t I 41 YES t } at <br /> NO <br /> __. PACE L <br /> . �-07Q185 <br />