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_ SAN JOP IN COUNTY PUBLIC HEALTH SF" ',ICES <br /> ENvIRONMENTAL HEALTH DIVISIOI. <br /> (UNDERGROUND STORAGE TANY PROGRAM - FARM TAHK INFORMATION FORM <br /> FACILITY/BITE INFORMATION (Complete thlt Fort for lath FARM TANK locttion) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F AMA- to- L litOV s(A Ae"7gfe <br /> x <br /> C ADDRESS (Street address of TANK location) PHONE I """ """ °O°` <br /> L <br /> I CITY 11 J� S1.�IE TIP CODE HEA T CROSS SiREE) <br /> Y L lHV cfi c,;, '�o �Ve-ye ( 1n <br /> CNECK dfdf if this ADDRESS should be used for Legal Notification <br /> OPERATOR tNFORMATION k ADDRESS (Complete If information Different from Above) <br /> NAME OPERATOR JOHTT�A.CT NAME <br /> f,f <br /> F <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 <br /> T 10-75- h}bW L,a �(� �- C'Lo`f) Sj8-Z-77 <br /> 0 CITY Lk <br /> klkyv S �T IIP CODE <br /> IZIR C'l �I S'S S D <br /> CNEC! NEJE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION k ADDRESS (Complete If Different from Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or SIRE'Sf��A�DD.RESS OWNER ?HOME 1 """ ""c" °°°c <br /> IN, Ua- �i< fit 'laIj Z <br /> E <br /> R CITY J „ E / SJILIE I1P CODE <br /> (,ccl[ t+4 5 3 70 <br /> C9ECf lilt if this ADDRESS should be used for Legal Notification <br /> CAee) AAproprlate dor <br /> I ACTIVE FARM TANK SITE (One or sort underground TANKS ) 1,100 gal. capacity) <br /> Y <br /> P EIEMPT 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 /> UMDER62DUKO TANK INFORMATION (List Additional lank information on separate sheet if needed) <br /> T TANK SIZE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL 02 <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> K <br /> 00,0 0 .t.vt¢� I-v�(�. [2f tM U <br /> F <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND 10 THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME TITLE DATE <br /> Ofl10E VSE OKC1 <br /> SEEPS I COMP I LOC CODE VDIST CGDE 1 ACTIVE UGi I EIEMPT UGT I CLOSED UGT SWEEPS PREM/SUB CODE DATE <br /> i 1 <br /> rpt :' ctr nI/se) <br />