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STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> F. 1 1-'01 RUBBER LINED ( 1 02 ALKYD LINING ( l 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (x) 07 UNLINED ( l 08 01Y,NOWN ( 1 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( 1 04 Ut(KNOWN I ) 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( 1 09 OTHER: ` <br /> VI PIPING <br /> A. ABOVEGP.OU140 PIPING: l 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( 1 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING. ( ) 1 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( RESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> f l ) <br /> 01 VISUAL (x1 02 STOCK INVENTORY l ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> { t ) 06 GP.OUIID WATER MOflITORING WELLS ( 1 07 PRESSURE TEST ( 1 09 NONE 9() 10 OTHER: �s <br /> VII-I---I CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CU•CENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME ) <br /> STORED STORED <br /> 01 ( ' 02 " 031111111111111 <br /> 01 " 02 ( 1 03 <br /> ( , 01 " 02 ( 1 03 1 I I I I I I l l l l l l <br /> t ) 01 ( 1 02 t ) 03 <br /> " O1 ( 102 ( ) 011 <br /> 1 1 01 ( 1 02 ( ) 03 <br /> 101 ( 102 O03 illlllllllll <br /> ' 101 _ (_' 02 f103LLLWIIIIIII <br /> ( ) 01 ( ) 02 <br /> t l 01 ( 02 1 01 I I I I Ll I I <br /> IS CC'ITAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES <br /> (�1 0 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PEN LT 1 O PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> • 04 FILI14G SIG SUFE ) PH NE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> aO'll1l•-*oaTIN5 e;EN�1' /-- — lC CITY CO ECOUNTY CODE <br /> CON:ArT c=C^rNV PH NE W/4p A CODE <br /> KATE 09 LAST INSrECTION INCOMPLIANCE <br /> 1_02 NO rPEpMIi APPROVAL DATE �TRANSACTION DATE — -�IOCAI PERMIT ID # <br /> KSC04-07'1185 ILL PAGE 2 <br />