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_ • STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 01 RUBBER LINED ( 1 02 ALKYD LINING 1 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> QQ 07 UNLINED ( 1 08 UNKNOWN 1 1 09 OTHER: <br /> F. f 1 01 POLYETMLENE WRAP 1 1 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN l ) 05 NONE <br /> f 1 06 TAR OR ASPHALT (yl 09 OTHER: (.'�r3Eeb�gss LL)r s>p <br /> VI PIPING <br /> A. ABOVEGROU140 PIPING: l ) 01 DOUBLE-MALLEO PIPE 1 1 02 CONCRETE-LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN '[1 07 NONE <br /> B. UNDERGROUND PIPING: ( 1 01 DOUBLE-WALLEO PIPE ( ) 02 CONCRETE-LINED TRENCH 1 ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) 1 04 PRESSURE l 1 05 SUCTION ( 1 06 UNKNOWN 1 1 07 NONE LbRr+fevLO.h <br /> VII LEAK DETECTION <br /> ('rl 01 VISUAL Q0 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS (/1 05 SENSOR INSTRUMENT t�O%k'AR.rF 1�whEs <br /> t 1 06 GROUND WATER MONITORING WELLS l 1 07 PRESSURE TEST ( 109 NONE 1x1 10 OTHER: ao-A _ (mak, cNe,Fe.cto rS <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASK (If KNOWN) CHEMICAL 100 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 1101 ( ) 02 O03IIIIIIIIIIIII <br /> M <br /> ( 101 ( ) 02 l 1031 I I 1111111111 <br /> llDl ( ) 02 I ) 03IIIIIiillllli <br /> l 1 01 ( ) 02 ( 1 03 <br /> 1 ) Ol O 02 ( 1 03 I j 1t�Lt IL I I I I <br /> l ) 01 ( ) 02 ( 1 03 <br /> 1 1 Ol_ ( ) 02 1 1 03 <br /> 1 ) 01 ( ) 02 ( 1 03_1_L <br /> ( ) 01 ( ) 02 1 1 03 <br /> f 1 Ol ( 1 02 ( 1 03 <br /> IS COYTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (�1 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND. TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON M ING ISIONATVPE) PKONE W/AREA CODE <br /> 2�La�a —Jaay s/08) <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTPATING AGENCY CITY CODE COUNTY COOK <br /> CONTACT PEFSON PNONE W/AREA CODE <br /> DATE Of LAST INSPECTION IN COMPLIANCE: 1 PERMIT APPROVAL DATE - TRANSACTION OATS LOCAL PERMIT IO <br /> 01 IfsO= NO p <br /> dSC04-070185 _ PAGE 2 <br />