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SAN J;IAUUIN LOCAL HEALTH DISTRICT <br /> UNprRogoj. TORAGE TANK PROGRAM - FARM TANK INFORMATIC LRM_ <br /> FACILITY/BITE INFORMATION mosplele this Fon for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F SD i B /IO �D <br /> A <br /> C ADDRESS (Street address of TANK location) PHONE I WITH AREA CODE <br /> �f 7�'3 <br /> 1 <br /> T CITY- STATE 41P CODE NEAREST CROSS STREET <br /> Y / i de C . _5 c r <br /> CN1C9fAf it this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION i ADDRESS (Cosplete if Inforsation Different froe Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE I WITH AREA CODE <br /> R <br /> A <br /> T <br /> 0 CITY STATE IIP CODE <br /> R <br /> CNECC NEIf if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION I ADDRESS (Cosplete If Different froe Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE I WITH AREA CODE <br /> W <br /> N <br /> E <br /> R CITY STATE IIP CODE <br /> LNECL NfAf if this ADDRESS should be used for Legal Notification <br /> Chec) Jp1ropriale bor <br /> T ACTIVE FARM TANK SITE (One or sore underground TANKS > 1,100 gal, capacity) <br /> Y <br /> P k/ 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 resoved or closed in place) <br /> UNDERGROUND TANK INFORMATION (List Additional tank inforsation on separate sheet it needed) <br /> T TANK SITE 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 <br /> 1 J J e re <br /> F /J E✓' <br /> O e o u cL ,S <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME ,.��� TITLEE DATE <br /> �L i <br /> offlCE WSF ONLY <br /> SWEEPS 1 COMP I LOC CODE 01ST CODE L ACTIVE UGT 1 EXEMPT UGT 1 CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EN 27 044 (12/88) <br />