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• • .u , <br /> SAN JOAOUIN COUNTY HEALTH SERVICES ! � V <br /> UNDERGROUND STORAGE TANK PROGRAM - FARM TANK INFORMATION FORM <br /> FACILITY/SITE INFORMATION (Complete this Form for each faciLity/site) A U G 12 1921 <br /> ARM or BUSINESS NAME Robertson Farms CONTACT NAME ENVIRONMENTAL <br /> HEALTH <br /> DBA Robertson & Sons Clifford Robe <br /> 4ARM PERVICES <br /> 1 kDDRESS (Street address of TANK location) PHONE # WITH AREA CODE <br /> 1 1777 W Linne Rd. (209) 635-0542 <br /> I TATE IP CODE EAREST CROSS STREET <br /> racy, Ca Ca 95376 Koster <br /> HECK HERE ifthis ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION & ADDRESS (Complete if Information Different from Above) <br /> AME JPERATOR CONTACT NAME <br /> Robertson Farms DBA Robertson & Sons Clifford Robertson <br /> (LING or STREET ADDRESS OPERATOR PHONE # WITH AREA CODE <br /> 27337 S Banta Rd (209) 635-0542 <br /> ITY TATE IP CODE <br /> Tracy Ca 95376 <br /> XNECK HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION & ADDRESS (Complete if Different from Above) <br /> AME Clifford E. Robertson. & Louella M. NER CONTACT NAME <br /> Robertson Revocable Family Trust of 2/1/9L Clifford Robertson <br /> �. 4 1AILING or STREET INFORMATION WNER PHONE # WITH AREA CODE <br /> 3456 W Linne Rd. (209) 635-0542 or 635-2412 <br /> ITY TATEIP CODE <br /> Tracy, Ca f 95376 <br /> X 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 /> X XEMPT 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 /> 1000 Diesel July 1 , 1991 <br /> /h o <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> AME ITLEATE <br /> Partner 6-7-91 <br /> OFFICE ONLY <br /> WEEPS OMP # LOC CODE DIST CODE # ACTIVE UGT # EXPEMT UGT 1 # CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 10/89 <br />