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SAN %QUIN LOCAL HEALTH DIST^ICT <br /> UNOERGROAM6 STORAGE TANK PROGRAM - FARM TANK INFORMAT lbwi ffll <br /> fACILITVIBITE INFORMp <br /> ATION (Complete this Fore for each FARM TANK location) HEATING OIL TANK <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F RINALDI 'S SUPERMARKET, INC. Gene W. Fong <br /> APHONEt WITH AREA coo■ <br /> C ADDRESS (Street address of TANK location) <br /> 1 4625 N. Duncan Road (209) 887-3507 <br /> T CITY Linden SPATE LIP CODE NEAREST CROSS STREET <br /> Y CA 95236 Hwy 26 <br /> X CYECA HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION I ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E NAILING or STREET ADDRESS OPERATOR PHONE I WITH AREA coos <br /> R <br /> A <br /> T <br /> 0 CITY STATE TIP CODE <br /> R <br /> CHECK MERE it this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION f, ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITH AREA CODs <br /> N <br /> N <br /> I <br /> R CITY STALE LIP CODE <br /> CHECK <br /> HERE if this ADDRESS should be used for Legal Notification <br /> Check ApProprlaie Dox <br /> TACTIVE FARM TANK SITE (One or more 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 550 Heating oil <br /> K 9 � tank removal <br /> N <br /> F <br /> 0 <br /> THIS FORM HAS BEE ED UNDER PENALTY OF PERJURY, AND TO THE BEST OF KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME TITLE DATE �✓ 2 �/ <br /> OFFICE U OYIY b <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE 1 ACTIVE UGI 1 EXEMPT UGT 1 CLOSED UGI SWEEPS PRGM/SUB CODE --DATE — <br /> ER 23 044 (12/88) <br />