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SAN JMUIN LOCAL HEALTH DIS CT k'NDER6ROL ORA6F TANK PROGRAM FARM TANK woRmAugggli <br /> FACILITY/SITE INFORMATION (Complete thie Form for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> fr4 r a� �e-j61A <br /> A <br /> C ADDRESS (Street address of <br /> TANK location) PHONE 1 ' •••• CouE <br /> L l � `� /`/ /Y 6tr� Ldcc� � � �k^� .2-0 3v2 - �Ssv <br /> YCITY1STATE ZIP CODE NEAREST CROSS STREET <br /> G6 �d eg i'.LC7r0 / <br /> yC CHECK NEIf if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION L ADDRESS (Complete If Information Different fro& Above) <br /> NAME OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE I WITH A"EA CODE <br /> R <br /> A <br /> T <br /> 0 CITY STALE lIP CODE <br /> R <br /> CNECI III[ if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION 1 ADDRESS (Complete If Different from Above) <br /> NAME OWNER CONTACT NAME <br /> S'14 XI l- <br /> 0 MAILING or STREET ADDRESS OWNER PHONE I WITH ARCA CODE <br /> W <br /> N <br /> E <br /> R CITY STATE 11P CODE <br /> CHECK MERE if this ADDRESS should be used for Legal Notification <br /> CAect ApproprYfif box <br /> T ACTIVE FARM TANK SITE (One or sore underground TANKS ) 1,100 gal. capacity) <br /> Y <br /> P g EXEMPT FARM TANK SITE (ALL underground TANKS at site to or ( 1,100 gal. capa(ity) <br /> E <br /> PERMANENILY 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 /> 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 /> K 5-00 196-6 — <br /> I t 1 II lrpC <br /> THIS FORM HAS BEEN COMPLETE UNDER PENALTY Of PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME / TITLE DATE � 2 �O <br /> Offlef USE Dino <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODEJ1 ACTIVE UG1 1 EXEMPT UGT 1 CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> Eli 23 044 (12/88) <br />