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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> 01 RUBBER LINED ) 02 ALKYD LINING 1 ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING f 1 OS GLASS LINLNG <br /> 1 ) 07 UNLINED IX) 06 UNKNOWN ( ) 09 OTHER: <br /> F, 1 1 01 POLYETHLEHE MAP ( 1 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION (A 04 UNKNOWN 1 ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT f ) 09 OTHER( <br /> VI PIPING <br /> f <br /> IA,. ABOVEGROUND PIPING( 1 ) 01 DOUBLE—WALLED PIPE l 1 02 CONCRETE—LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIES) 1 ) 04 PRESSURE ( ) 05 SUCTION ( 1 06 UNKNOWN (N 07 HONE <br /> j8. UNDERGROUND PIPING: ( 101 DOl1RLE—WALLED PIPE f ) 02 CONCRETE—LINE° TRENCH ( ) 03 GRAVITY <br /> (__(CHECK APPROPRIATE BOX(ES) (k'1 04 PRESSURE ( 1 OS SUCTION f 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> r( ) <br /> 01 VISUAL (,Y) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS 1 105 SENSOR INSTRUMENT <br /> 1 1 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IR YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> GUC4ENTLY PREVIOUSLY DELETE CASK III KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> 9TORED STORED <br /> 02 K I 03 f l l l l l l l l l <br /> "°2 1 ' 03 I I I I I I I I I I I I I <br /> ( 1 Ol t 1 02 ( 1'03 <br /> 101 1102 1103.-IIIIIIIIIIIII <br /> " 01 " 02 11 03 LI I I 1 1 1 1 1 1 1 <br /> Dl 1 02 " 031 1 1 1 1 1 1 111111 _ <br /> ) 01 1a02 1 ) 031111111111111 <br /> 1 l 01 1 1 02 ( 1 03 <br /> � 1 ) 01 ( , oz 1 ) 03 I <br /> 1 1 01 ( ) 02 ( , 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> LIS CONTAINER LOCATED ON AN AGRICULTURAL FARM! f 1 01 YES (r) 02 NO <br /> THIS FORM: XAS BEEN COMPLETED UN)ER 'ME PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> F .__ <br /> PERSON + (LINO ISIONATUR 1 ► NC W/AREA CODE <br /> OR LOCAL AGENCY U 0 LY <br /> ADMINISTRA"INO AGENCY CITY COOK COUNTY CODE <br /> CONTACT PERSON -- _ PHONE W/AREA C009 <br /> jDATt Of UST SNSP[CTION 2N COMPLIANCE <br /> PERMIT AFPROVAI DATE TRANSACTION DAT[ IOCAL PERMIT SD t <br /> ( 1 O1 YES f 1 02 ND <br /> hSC04-070165 PAGE 2 <br />