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(c)) 1ST Qtr 2nd Qtr 3rd Qtr 4th Qtr Year: _________________ This report contains information for: Entire facility Part of facility Date submitted to Chicago Department of Public Health:________________________ REPORTING PERIOD: FACILITY INFORMATION FACILITY NAME: STREET ADDRESS: CITY: PHONE NUMBER: STATE: PRIMARY INDUSTRIAL CLASSIFICATION(SIC) CATEGORY IS FACILITY PERMITTED BY IEPA OR USEPA? ZIP: WARD: PRIMARY SIC NO._________________ NAIC CODE:_________________ YES NO IF YES, IEPA OR US.

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