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SAN JOAQUIN LOCAL HEALTH DIF' RICT <br />UNDERGISTORAGE TANK PROGRAM - FARM TANK INrORMA1 __ ORM <br />FACILITY/SITE INFORMATION (Cosplete this Fon for etch FARM TANK location) <br />MUM INIURnAIIUN a ADDRESS (C0e01ete if Inforution Different frae Above) <br />FARM or BUSINESS NAME <br />OPERATOR CONTACT NAME <br />CONTACT NAM <br />j <br />EXEMPT FARM TANK SITE (ALL underground TANKS at site to or ( 1,100 gal. capacity) <br />A <br />MAILING at STREET ADDRESS <br />OPERATOR PHONE I WITH okko cook <br />R <br />--P <br />C <br />ADDRESS (Street addres1 TANK location) <br />PHONE 1 WITH "&A Gross <br />L <br />J <br />I <br />6 - <br />j <br />R <br />0 <br />%� <br />STATE <br />ZIP COD <br />NEAREST C SS Sf%tEET <br />! <br />CNECC YEAS it this ADDRESS should he used for Legal Notification <br />GI <br />SCIECK <br />ME if this ADDRESS should he <br />used for Legal Notification <br />MUM INIURnAIIUN a ADDRESS (C0e01ete if Inforution Different frae Above) <br />rturticrt UNNLK IMIURMATIUM i ADDRESS (Coeolete if Dlffor■nt Ira• Ahawal <br />NAME <br />OPERATOR CONTACT NAME <br />0 <br />P <br />METHOD Of CLOSURE <br />IF PERMANENTLY CLOSED <br />EXEMPT FARM TANK SITE (ALL underground TANKS at site to or ( 1,100 gal. capacity) <br />E <br />MAILING at STREET ADDRESS <br />OPERATOR PHONE I WITH okko cook <br />R <br />--P <br />A <br />T <br />0 <br />CITY <br />STATE <br />IlP CODE <br />R <br />0 <br />CNECI NEAE if this ADDRESS should he used for Legal Notification <br />CNECC YEAS it this ADDRESS should he used for Legal Notification <br />rturticrt UNNLK IMIURMATIUM i ADDRESS (Coeolete if Dlffor■nt Ira• Ahawal <br />va•ki eprWpnare 00a <br />I <br />Y <br />NAME <br />OWNER CONTACT NAME <br />P <br />E <br />METHOD Of CLOSURE <br />IF PERMANENTLY CLOSED <br />EXEMPT FARM TANK SITE (ALL underground TANKS at site to or ( 1,100 gal. capacity) <br />0 <br />NAILING orSTREET ADDRESS <br />OWNER PHONE 1 WITH ANCA cook <br />W <br />--P <br />N <br />E <br />R <br />CITY <br />SLATE <br />11P CODE <br />0 <br />CNECI NEAE if this ADDRESS should he used for Legal Notification <br />va•ki eprWpnare 00a <br />I <br />Y <br />TANK SIZE <br />(GALLONS) <br />ACTIVE FARM TANK SITE (One or sore underground TANKS ) 1,100 gal. capacity) <br />P <br />E <br />METHOD Of CLOSURE <br />IF PERMANENTLY CLOSED <br />EXEMPT FARM TANK SITE (ALL underground TANKS at site to or ( 1,100 gal. capacity) <br />K <br />�Oo <br />PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site rew-ed :r close, ig place) <br />.R..MR IAm 1nIWRla Ulla Illet AODI910RAI tint Inlorution an &•narato &hoot it nanaaal <br />T <br />A <br />N <br />TANK SIZE <br />(GALLONS) <br />CHEMICALS STORED <br />CURRE TLY OR PREVIOUSLY <br />ESTIMATED DATE LAST USED <br />If CURRENTLY EMPTY <br />METHOD Of CLOSURE <br />IF PERMANENTLY CLOSED <br />DATE Of REMOVAL OR <br />CLOSURE IN PLACE <br />K <br />�Oo <br />1 <br />59 <br />--P <br />N <br />0 <br />mla rutin NAs 1UN UUM1'LEIED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT <br />TITLE DATE _/ — <br />NSE <br />LSWEEPS I[COMP 1 FLOC CODE[DIST CODEf1 ACTIVE UGTf1 EIEMPT UGT11 CLOSED UGTI SWEEPS PRGMISUB CODE I DATE <br />EH 23 044 (12/BB) <br />