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STATE IO NUMBER <br /> CONTAINER CONSTRUCTION <br /> 1. f 1'01 RUBBER LINED l 1 02 ALKYD LINING 1 1 OS EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING, <br /> 1 1 07 UNLINED 1 ) 00 UNKN()WH (X 1 09 OTHER' Fiberglass Coated <br /> F. 1 1 01 POLYETHLENE WRAP l 1 02 VINYL WRAPPING 1 1 03 CATHODIC PROTECTION ( 1 04 LRIKHOWN f 1 05 NONE <br /> f 1 06 TAR OR ASPHALT 1 1 09 OTHER: <br /> VI PIPING _ <br /> iA. ABOVEGROUID PIPING: 1 1 01 OOUSLE-WALLED PIPE ( 1 02 CONCRETE-LIHEO TRENCH ( 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE l 1 05 STICTION 1 1 06 UWHOWN f 1 07 NONE <br /> f6. L41DERGROLRID PIPING: (\I 01 DOUBLE-WALLED PIPE l 1 02 CONCRETE-LINED TRENCH ( 1 03 GRAVITY <br /> 1 'CHECK APPROPRIATE BOXIEST l 1 04 PRESSURE ( 1 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> +II LEAK DETECTION <br /> I ) Ol VISUAL 1 1 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS " 05 SENSOR INSTRUMENT - <br /> 1 1 O6 GROU101 WATER MONITORING WELLS l ) 07 PRESSURE TEST l 1 09 NONE 1 1 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 /> 0:V09INTLY PREVIOUSLY DELETE CASK IIF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 1X 1 01 ( 1 02 ( ) 03 IF 1"Y ILI I I I I I I I I <br /> 1 1 Ol ( ) 02 ( 1 03 I I I <br /> ( 1 Ol ( 1 02 ( 1 03 L��L <br /> f l 01 1 1 02 ( 1 03 <br /> 01 ( 102 ( 103 I I I I I I I I I I I I I <br /> ( 1 01 t 1 02 ( 1 03 <br /> I I ) 01 1 1 02 O 03 <br /> 1 1 01 1 1 02 ( 1 03 LI I I I I I I I I I I I <br /> 11 01 1 1 02 O 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> I ) 01 110: 1OS ' IIIIIIIIIIII <br /> 3 COfRAINER LOCATED ON AN AGRICULTURAL FARM? 1 1 01 YES 1X1 02 NO -� <br /> TRIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> Ce SOVFI G ISIGNATU l / PHONE W/AREA CODE — <br /> F"OP. LOCAL AGENCY USE ONLY <br /> 44+OYSTPATINS A.ENCY -- ——— — 'CITY CODE COUNTY COOL <br /> t�'IL� IL <br /> �IC ONTACT -ECSON PHONE W/ARtA CODE <br /> OATE OA_ 'IST INS c CCTION TIN COc1L IE SClI I-OT ND �Pf RMIT APPROVAL OATC_ - L E IS �,1,OCAL PERMIT IO-R <br /> n$C04-0'7165 I MAY 2 C 198(7 PAGE 2 <br /> ENVIRuMENTAL HEALTH <br /> FERfAIT/SERVICES <br />