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SAN Jr QUIN LOCAL HEALTH DIST !CT <br /> UNDEROROUhY-20RAGE TANK PROGRAM FARM TANK INFORMATIDNTORM <br /> iACILM181TE INFORMATION (Complete thle Fon for etch FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> A <br /> C ADDRESS (Street address of TANK location) PHONE 1 WITH •mmm coot <br /> L &7 <br /> T <br /> CITY 5 STAT _ )IP CODE NEAREST CROSS STREET <br /> fNECE REAE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION 1 ADDRESS (Complete If Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 WITH ••EA CODE <br /> R <br /> A <br /> T <br /> 0 CITY STATE IIP CODE <br /> R <br /> fNftf REAE if this ADDRESS should be used for Legal Notification 166114 W li. —j <br /> PROPERTY OWNER INFORMATION 1 ADDRESS (Complete It Different from Above) <br /> ELsed <br /> OWNER CONTACT NAME NU-V 31989 <br /> DDRESS OWNER PHONE 1 °1iX mEEm CODIi7^' "'^` 7r^ <br /> STATE ZIP CODE <br /> this ADDRESS should be used for Legal Notification <br /> or <br /> T ACTIVE FARM TANK SITE (one or sore underground TANKS > 1,100 gal. capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site to or ( 1,100 gal. capacity) <br /> E <br /> PERMANENTLY 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 /> T TANK SIZE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE Of REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY If CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K d-- nD <br /> U <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME ✓ ,Y J TITLE DAT <br /> 7//f0 <br /> Orri f USE ONLY <br /> SWEEPS I COMP 1 LOC CODE DIST CODE 1 ACTIVE UGT 1 EXEMPT UGT 1 CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 (12/88) <br />