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SAY OAQIJIN LOCAL HEALTH V fRICT <br /> U"ft1l OUND STORAGE TANK PROGRAM - FARM TANK INFORA>i�ON FORM <br /> FACILITY/SITE INFORMATION (Complete this Fon for each FARM TANK location) <br /> rA <br /> BUSINESS NAME CONTACT NAME <br /> i <br /> reet address of TANK location) PHONE 1 RITR AREA coca <br /> 7 N. Davis Road STATE IIP CODE NEAREST CROSS STREETCA 95242 1 ;ERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION b ADDRESS (Complete if Information Different from Above) <br /> EA <br /> OPERATOR CONTACT NAME <br /> DDRESS OPERATOR PHONE I WITH AREA CODE <br /> O CITY STATE 11P CODE <br /> R <br /> CNECI YEAf it this ADDRESS should 6e used for Legal Notification <br /> PROPERTY OWNER INFORMATION 1 ADDRESS (Complete it Different from Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE I WITH AREA CODE <br /> W <br /> N <br /> f. <br /> R CITY STATE ZIP CODE <br /> CNECI HERE if this ADDRESS should he used for Legal Notification <br /> Cbect ippropriato Box <br /> Y ACTIVE FARM TANK SITE (One or more underground TANKS ) 1,100 gal. capacity) <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site R 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 inforeation 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 <br /> N If PERMANENTLY CLOSED CLOSURE IN PLACE <br /> K 350 gasoline 12/8/97 Tank Removal Dec. 9, 1997 <br /> I 550 diesel 12/8/97 Tank Removal Dec . 9, 1997 <br /> N <br /> F <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME TITL GATE <br /> '11 <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP t LOC CODE DIST CODE t ACTIVE UGf I EXEMPT UGT I CLOSED UGT SWEEPS PRfiM/SUB CODE DATE <br /> EH 23 044 (12180) <br />