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SAN JOAQUIN LOCAL HEALTH DIRTRICT <br /> UNDERGF' STORAGE TANK PROGRAM - FARM TANK INFORMAT 8 <br /> FACILITY/SITE INFORMATION (Complete Ais Fore for each FARM TANK location) <br /> FARM or BUSINESS NAME ,// CONTACT NAME <br /> A E Q/1 D�` <br /> C ADDRESS (Street a ss of TANK location) PHONE F <br /> 1 <br /> T CITY �Y STATE1111 CODE NEAREST CROSS STREET <br /> Y Y <br /> CHECX HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION & ADDRESS (Complete if Information Different from Above) <br /> NAME / G! /ALN ��tA't-- OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS DD c, OPERATOR PHONE f WITH AREA COOK <br /> A / <br /> T —— <br /> 0 CITY STAT£ 21P CODE <br /> R S7k r , <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION 6 ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE f WITH AREA CODE <br /> W <br /> N <br /> E <br /> R CITY STATE 21P CODE <br /> CHECI HERE if this ADDRESS should be used for Legal Notification <br /> Cheof Apfropriate box <br /> T ACTIVE 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 m 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 CHC'MICALS STORED EST(NATED DnIE LASi USED MENOO 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 /> N <br /> F <br /> O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> N E - TITk/6� DATE <br /> /y Ci <br /> OFFICE HSE ONLY <br /> SWEEPS f COMP 1 LOC CODE DIST CODE f ACTIVE UGT t EXEMPT UGT t CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 (12188) <br />