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low <br /> USAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FARM TANK INFORMATION FORM <br /> FACILITY/SITE INFORMATION (Complete this Form for each facility/site) <br /> ARM or BUSINESS NAME CONTACT NAME <br /> T-54-C' DN.9 P/GiS�T/o �/ST % ��•C C'f/✓1 <br /> DRESS (Street address of TANK location) PHONE # WITH AREA CODE <br /> 2�grs KfJ<�SO.(/ ,L�oR.a Z�J -835- -sib �o <br /> ITY ^ - TATE IP CODE EAREST CROSS STREET <br /> TiZAG� GA 05376 CA?l7-ev,�sTT <br /> HECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION & ADDRESS (Complete if Information Different from Above) <br /> E OPERATOR CONTACT NAME <br /> (LING or STREET ADDRESS OPERATOR PHONE # WITH AREA CODE <br /> 14 DA <br /> ITY TATE IP CODE <br /> HECK HERE if this ADDRESS should be used for Legal Notification 77771 <br /> PROPERTY OWNER INFORMATION & ADDRESS (Complete if Different from Above) <br /> AME OWNER CONTACT NAME <br /> AILING or STREET INFORMATION OWNER PHONE # WITH AREA CODE <br /> ITY TATE r <br /> P CODE <br /> HECK HERE if this ADDRESS should be used for Legal Notification <br /> Check Appropriate Box <br /> CTIVE FARM TANK SITE (one or more underground TANKS > 1,100 gal. capacity) <br /> %EMPT FARM TANK SITE. (ALL underground TANKS at site = to or < 1,100 gal. capacity) <br /> ERMANENTLY 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 /> TANK SIZE CHEMICALS STORED STIMATED DATE LAST USED MEHTOD OF CLOSURE DATE OF REMOVAL OR <br /> (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> THIS FORM S BEEN CO PtETEb UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> AME ���iiYV ITLE ATE <br /> /Its iZ <br /> OFFICE USE 0 LY <br /> WEEPS # OMP # LOC CODE I DIST CODE # ACTIVE UGT # EXPEMT UGT # CLOSED UG7 SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 10189 <br />