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SAN )CACUIN COUNTY PUBLIC 3EALT4 SERVICES <br /> i �� <br /> UNDE G.RG= STORAGE TANK PROGRAM - FARM TANK I W ORMAT"Uq FORM <br /> FACILITY/SITE INFORMATION (Complete this Form for each fac:(ity/site) <br /> FARM or BUSINESS NAME ;CONTACT NAME <br /> t ' S ae n 1 In <br /> :I NODRESS kSt,wt address of TANK location) HONE # WI H AREA CODE <br /> 4 11n9k NLlezkp�sx509 - 5 <br /> �' IrYO I i IZ( C E EAREST CROSS STREET <br /> gym, <br /> HECK HERE if this ADDRESS should be used for legal Notification :r.;IIF „ <br /> 1 OPERATOR INFORMATION S ADDRESS (Complete if Information Oifferent from Above) DEC 1 7 1992 <br /> 4AME PERATOR CONTACT NAME ENVIRONMENTAL HEPLTf- <br /> Sal dal /� i ERIII.15 <br /> R <br /> AILING o STREET ADOR as PERAi ORP NE # <br /> WITH ARE CODE <br /> -c , q - <br /> t� Mort \A [ E <br /> HECK HERE if this ADDRESS should be used for legal Notification <br /> PROPERTY CWNER INFORMATION 8 ADDRESS (Caaalete if Different from Above) <br /> AME NER CONTACT NAME <br /> W -Ro S <br /> pepylkeg <br /> ILING Jr STREET INFORMATI .ER +E # WITH AREA CODE <br /> 7VP <br /> IT TpT :7 - <br /> NECK HERE if this ADDRESS should be used for Legal Notification <br /> Check Appropriate Box <br /> 4 CTIVE FARM TANK SITE One or more underground TANKS > 1,100 gal. capacity) <br /> %EMPT FARM TANK SITE (ALL underground TANKS at site - to or < 1,100 gal. capacity) <br /> ER•MANENTLY 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 MEHTOO OF CLOSURE DATE OF REMOVAL OR <br /> (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> I <br /> I1. 1 no Grillo OaPP014- he ladl, r) <br /> eat ue.e, <br /> THIS FORM HAS BEEN COMPUTED UNDER PENALTY OF PER:URY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> ATE/2 <br /> r N�f7 <br /> v <br /> OFFICE U ONLY <br /> JEEPS # CMP # LOC CODE DIST CWE I # ACTIVE UGT # EXPEMT UGT I # CLOSED UGT SWEEPS rRGM/SUB CODE DATE <br /> EH 23 044 10/89 <br />