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Underground Storage Tank Program - Farm Tank Information Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CON"I'ACr NAME <br /> A GEORGE DIMOTAKIS 3iO3GE C . DIMOTAKIS <br /> C ADDRESS(Street addn=of TANK location) PHONE# (withareacode) <br /> L <br /> L 713 INDuSTRIAL PARK DRIVE 209 823-7726 <br /> I CITY STATEZIP CODE NEAREST CROSS STREET <br /> T :. ANTECA CA 537)6 FESS"•1ER <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete If Information different from above.) <br /> O NAME OPERATOR CONTACT NAME <br /> P GEORGE ''AI. DIMOTAKIS iEOTGE "+, ;I:OTAKIS <br /> E MAILING or STREET ADDRESS OPERATOR PI IONS A (with area talc) <br /> R <br /> A P. 0. 13OX 695 209 823-7726 <br /> T CITY STATE ZIP CODE <br /> 0 MANTECA CA 95336 <br /> RX CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME OWNER CONTACl'NAME <br /> 0 <br /> NMAILING or STREET ADDRESS OWNER PIIONE#(with area code) <br /> E <br /> R CITY STA'IB LIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification 1.4 <br /> CHECK APPROPRIATE BOX SEP 2 0 1989 <br /> .I, ACTIVE FARM TANK SITE (One or more underground TAt jWhv�(jpd%p0)gI pip e4y) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> E 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 SIORP.D ESt'IMATED DATE LAST USED M0Il10D OF CLOSURE DATE OF REMOVAL Olt <br /> A (GALLONS) C7URREMLY OR PREVIOUSLY IF CURRENI'LY EMP'T'Y IF PIIRMANf•N'ILY CLOSED CUISUM::IN PLACE <br /> K 2200 `10TOR VEZ� <br /> I <br /> N <br /> F <br /> 101 1 <br /> TIES FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND 1'0 THE HESTOF MY KNOWLEDGE,IS TRUE AND CORREL-l'. <br /> NAME 'TITLE <br /> n, fl,, DATE �O AUP Q <br /> OFFICE USE ONY <br /> SW[itiPSa CUMPa IAC CODL' UIS'I'CODL MACIIVEUG'IdLxLMPTUG'I' sCLOSLDUGI SWW41S 11I(GM/SUb CODL UA'lli <br /> EH 23 044(12/M) <br />