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STATE ID NUMBER 00000054840001 <br /> CONTAINER CONSTRUCTION <br /> E, t ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( l 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 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: t ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION t ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( D 05 SENSOR INSTRUMENT <br /> t ) 06 GROUND WATER MONITORING WELLS ( l 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: <br /> VIII 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 /> CURRENTLY PREVIOUSLY DELETE CA$# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> (70" 01 ( D 02 ( ) 03 r®S ►�L�i <br /> t ) 01 ( ) 02 t ) 03 tj <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> i ) 01 ( ) 02 ( ) 03 <br /> ( D Ol ( ) 02 ( ) 03 <br /> t 1 Ol ( D 02 ( ) 03 <br /> t ) Ol ( ) 02 ( ) 03 <br /> t ) Ol t ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( Y 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN.5jWLETED UNDER THE PEN TY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> P SONZONATURE) PMO E W EA C D <br /> �^ <br /> LOCAL A NCY USE', ONLY <br /> ADMINS TkATZN* ENCY CITY COOK COUNTY CODE <br /> G <br /> CONTACT PERSON PHO W/AREA CODE <br /> Ggal <br /> DATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( ) 01 YES t ) O2 NO <br /> Fl$CO$-b701aS f i0/lt!!8S) PAGE 2 <br />