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SAN OAQUIN LOCAL HEALTH DI*RICT UNDERGROUND STORAGE TANK PROGRAM - FARM TANK INFORMATION FORM FACILITY/BITE INFORMATION (Complete this Form for each FARM TANK location) OPERATOR INFORMATION A ADDRESS (Complete if Information Different from Above) FARM or BUSINESS NAME OPERATOR CONIACT NAME ESTIMATED DATE LAST USED If CURRENTLY EMPTY CONTACT NAME DATE Of REMOVAL OR CLOSURE IN PLACE P MAILING or STREET ADDRESS OWNER PHONE 1 WITH AAKA Goa& N f. ct.F�p '�-23 �o9 7a�-S�yy E MAILING or STREET ADDRESS OPERATOR PHONE 1 MTTO AR" GOOK C ADDRESS !Street address of TANK location) A PHONE 1 WITH AA&A coag I T CNECE MERE if this ADDRESS should be used for Legal Notification T Y City STAGE (-1 11P SDE `?� ! 3 7 NEAREST C 0 S STREET STATE 11P CODE CHECK NEAE it this ADDRESS should be used for Legal Notification OPERATOR INFORMATION A ADDRESS (Complete if Information Different from Above) PROPERTY OWNER INFORMATION A ADDRESS (Complete it Different from Above) NAME OPERATOR CONIACT NAME ESTIMATED DATE LAST USED If CURRENTLY EMPTY METHOD OF CLOSURE If PERMANENTLY CLOSED DATE Of REMOVAL OR CLOSURE IN PLACE P MAILING or STREET ADDRESS OWNER PHONE 1 WITH AAKA Goa& N f. ct.F�p '�-23 �o9 7a�-S�yy E MAILING or STREET ADDRESS OPERATOR PHONE 1 MTTO AR" GOOK R A T CNECE MERE if this ADDRESS should be used for Legal Notification 0 CITY STATE 11P CODE R CNECE MERE it this ADDRESS should be used for Legal Notification PROPERTY OWNER INFORMATION A ADDRESS (Complete it Different from Above) Chea Appropriate Dox I Y, NAME OWNER CONTACT NAME ESTIMATED DATE LAST USED If CURRENTLY EMPTY METHOD OF CLOSURE If PERMANENTLY CLOSED DATE Of REMOVAL OR CLOSURE IN PLACE 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITH AAKA Goa& N f. ct.F�p '�-23 �o9 7a�-S�yy R CITY /` ocke rbR, 1 STATE ZIP CODE b CNECE MERE if this ADDRESS should be used for Legal Notification Chea Appropriate Dox I Y, TANK SIZE (GALLONS) ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gal, capacity! ESTIMATED DATE LAST USED If CURRENTLY EMPTY METHOD OF CLOSURE If PERMANENTLY CLOSED DATE Of REMOVAL OR CLOSURE IN PLACE P'" E Chit'% EXEMPT FARM TANK SITE (ALL underground TANKS at site • to or ( 1,100 gal. capacity) Lxa nJ AA %PmiJ%}< PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) UNDERGROUND TANK INFORMATION (List Additional tank information on seoarate sheet it needed) T N TANK SIZE (GALLONS) CHEMICALS STORED CURRENTLY OR PREVIOUSLY ESTIMATED DATE LAST USED If CURRENTLY EMPTY METHOD OF CLOSURE If PERMANENTLY CLOSED DATE Of REMOVAL OR CLOSURE IN PLACE K Chit'% �. SUe,. Lxa nJ AA %PmiJ%}< .3 I N F 0 THIS FORM HAS BEEN COMPLETED UNDER PENALTY Of PERJURY, AND TO THE BEST OF MY KNOWLEDGE, 18 TRUE AND CORRECT NAME TITLE GATE #iLwiz &- /��7 Arrr-r ear AVIV SWEEPS 1 COMP 1 LOC COOS DISI CODE11 ACTIVE UGI I 1 EXEMPT UGT 1 CLOSED UGI SWEEPS PRfiM/SOD CODE DATE EN 23 044 (12/88)