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Underground Sto, ,,ge Tank Program - Farm Tan'.aformation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> A Joe Gotelli & Sons Al Gotelli <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> 1 9189 N. Ashley Lane 209 931-4392 <br /> L <br /> I CITY STATE ZIP CODE I NEAREST CROSS STREET <br /> T I tockton CA 95212 Hildreth Lane <br /> Y I I CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete if information different from above.) <br /> O NAME OPERATOR CONTACT NAME <br /> P N/A <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> R <br /> A <br /> T CITY STATE I ZIP CODE <br /> 0 <br /> R CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) <br /> NAME OWNER CONTACT NAME <br /> 0 N/A <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E <br /> R CITY STATE I ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> ,1, ACIIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> E XX 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 INPLACE <br /> N <br /> K 4,000 Gasoline Removed 2-9-88 <br /> 4,000 Gasoline Removed —9-88 <br /> F <br /> O <br /> THIS FORM BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> TITLE DATE <br /> OFFI ONLY, - �i <br /> SWEEPS# bOMP# 1 LOC CODE DIST CODE#ACTIVE UGT #EXEMPT UGT #CLOSED UGT S WEEPS PRGM/SUB CODE DATE <br /> EH 23 044(12/88) <br />