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\.ol SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE$ <br /> UNDERGROUND STORAGE TANK PROGRAM - FARM TANK INFORMATION FORM MAY 2 7 1992 <br /> FACILITY/SITE INFORMATION (Complete this Form for each facility/site) ENVIRONMENTAL HEALTH <br /> r• <br /> gt <br /> SS NAME ONTACT NAME <br /> address of TANK cation) HONE # WITH AREA CODE <br /> TATE IP CODE E ST CROSS STREET <br /> ,5 Z <br /> EC HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION & ADDRESS (Complete if information Different from Above) <br /> AME PERATOR CONTACT NAME <br /> AILING or STREET ADDRESS PERATOR PHONE # WITH AREA CODE <br /> ITY TATE tP CODE <br /> HECK HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION & ADDRESS (Complete if Different from Above) <br /> AME WNER CONTACT NAME <br /> AILING or STREET INFORMATION WNER PHONE # WITH AREA CODE <br /> 'I TY TATE IP CODE <br /> HECK-HERE if this ADDRESS should be used for Legal Notification <br /> Check Appropriate Box <br /> CT i VE FARM TANK SITE (One or more underground TANKS > 1,100 gal. capacity) <br /> EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gal. capacity) <br /> ERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) <br /> UNDERGROUND TANK INFORMATION (List Additional tank information on separate sheet if needed) <br /> TANK SIZE CHEMICALS STORED STIMATED DATE LAST USED MEHTOD OF CLOSURE DATE OF REMOVAL OR <br /> (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> so..° <br /> z <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> AME a c L ITLE� ATE 1 <br /> am <br /> OFFICE USE ONLY <br /> WEEPS # OMP # LOC CODE DIST CODE # ACTIVE UGT # E%PEMT UGT # CLOSED UGT SWEEPS PRGM/SUR CODE DATE <br /> EH 23 044 10/89 <br />