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STATE ID NUMBER 00000060326001 <br /> CONTAINER CONSTRUCTION <br /> E. [ ) 01 RUBBER LINED ( ) 02 ALKYD LINING f 1 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED i ) 08 UNKNOWN ( ) 09 OTHER. <br /> F. (X) 01 POLYETHLENE WRAP f 3 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION ( 1 04 UNKNOWN C ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER' <br /> VI PIPING <br /> EB. U"�IDERGROUNO <br /> EGROUND PIPING: C 1 01 DOUBLE-WALLED PIPE [ ) 02 CONCRETE-LINED TRENCH C 1 03 GRAVITY <br /> CK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( 1 07 NONEEl <br /> PIPING ( ) 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH (X) 03 GRAVITY <br /> CK APPROPRIATE BOX(ES) ( ! 04 PRESSURE ( 1 05 SUCTION [ ) 06 UNKNOWN f 1 07 NONE <br /> VII LEAK DETECTION <br /> i ] 01 VISUAL 4ktC2 STOCK INVENTORY [ ) 04 VAPOR SNIFF WELLS i 1 05 SENSOR INSTRUMENT <br /> 1 06 GpCUND WATER MOJITORI�)G WELLS C 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER= <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF 70'J CHECKED "ES TO IV-F '70U APE NOT PEPJIPED TO CCMPLETE THIS SECTION <br /> CUPRET7TLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> S-07-ED STOPED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ] 01 ( ) 02 ( ) 03 <br /> i ) 01 ( ) 02 ( ] 03 <br /> i ) 01 f ) 02 ( 1 03 <br /> f ] 01 ( 1 02 ( ) 03 <br /> 02 ( ) 03 <br /> ( 1 O1 f ) 02 ( l 03 � <br /> [ ) 01 C ) 02 ( ) 03 <br /> ( 1 01 i 1 02 ( ) 03 _1 <br /> ( ) 01 F ) 02 ( 1 03 <br /> ENVIF�U; OLNTAL HEALTH <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS F ERIAI S ERVIC�- <br /> IS CONTAINER LOCATED ONAN AGRICULTURAL FARM? ( ) O1 YES (X) 02 NO <br /> THIS FSRM AS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PHONE W/,AREA CODE <br /> F PSON IL N <br /> FOR LOCAL AGENCY USE ONLY <br /> CITY CODE COUNTY CODE <br /> '.O"INISTPATIN3 AGENCY <br /> PHONE W/AREA CODE <br /> CONTACT PEPSON <br /> PATE OF LAST INSPECTION IN COMPLIANCE <br /> PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO t3 <br /> ( ) O1 YES t ) 02 NO <br /> PAGE 2 <br /> i`SC04-070185 (10/18/85) <br /> Ad <br />