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STATE ID NUMBER 00000063026002 <br /> CONTAINER CONSTRUCTION <br /> E( ) <br /> RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION ( l 04 UNKNOWN (X) 05 NONE <br /> 06 TAR OR ASPHALT f 1 09 OTHER: <br /> VI PIPING <br /> A ABOVEGROUND <br /> PIPING- ( 01LEO PIP ( OC6E- ETR(N ( 3 GRAVITY <br /> (CHECK AOPRIATEBOXES) ( ) 04 PRESSURE05 SUCTION ( 100UNKNNOWN ) 07NE <br /> 9. (CHECK AAPROPRIATE•BOX(ES) ( ( 0104DOUBLE-WALLED'Q5 SUCTION CONCRETE-LINED <br /> UNKNOWNTRENCH <br /> ( 07 NONE <br /> 3 GRAVITY <br /> NONE <br /> VII LEAK DETECTION <br /> I 1 01 VISUAL (X) 02 STOCK INVENTORY l l 04 VAPOR SNIFF WELLS ( 105 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS 0< 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <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 CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STORED <br /> ( 1 01 ( 7 02 ( 1 03 <br /> ( 1 01 ( ) 02 l 1 03 <br /> f 7 Ol ( 1 02 ( 1 03 <br /> ( ) 01 ( ) 02 ( 7 03 <br /> ( 1 01 ( ) 02 ( 1 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 7 01 ( ) 02 ( ) 03 <br /> f l 01 ( ) 02 ( ) 03 <br /> ( ) O1 ( 1 02 ( 1 03 <br /> ( ) 01 ( ) 02 f ) 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 FOR AS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FIL NO (SIONATU PHONE W/AREA COD! <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY COOK COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DAT! OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> ( ) O1 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />