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SAN IAQUIN LOCAL HEALTH DI RICT <br /> UNDER440 STORAGE TANK PROGRAM - FARM TANK INFORMAT° UN FORM <br /> FACILITYISITE INFORMATION (Complete this Fon for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F c <br /> A <br /> C ADDRESS (Street address of TANK location) PHONE 1 WITH AREA Loot <br /> 1 c � k o e �U — - oy <br /> I <br /> T CITY ST TE IIP CODE NEAREST CROSS STREET <br /> Y i c� _�- _ vc� <br /> -,, CHECI HEAf it this ADDRESS should be used for legal Notification <br /> OPERATOR INFORMATION L ADDRESS (Complete if Information Different from Above) <br /> 11 NAME OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE I WITH ARCA CLmm <br /> R <br /> A <br /> T <br /> 0 CITY STATE 11P CODE <br /> k <br /> CHECI HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION It ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE I WITH AREA Lalli <br /> W <br /> N <br /> E <br /> R CITYSTALEIIP CODE <br /> CHICI HERE if this ADDRESS should be used for Legal Notification <br /> CAec1 AAAroArlate box <br /> T ACTIVE FARM TANK SITE (One or wre underground TANr,S > 1,100 gal. capacity) <br /> Y <br /> P <br /> E EXEMPT FARM TANK SITE (ALL underground TANKS at site to or ( 1,100 gal. capacity) <br /> nrownuEH%v CLOSC^ ACM w. A"' <br /> r R F 'A^^ PJAT' TALL 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 <br /> K O o <br /> N — — <br /> F <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME / TITLE DATE <br /> 2 c <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE 1 ACTIVE UGT t EXEMPT UGT 1 CLOSED UGT SWEEPS PR6M/SUB CODE DATE <br /> EH 23 044 (12/BO) <br />