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SAN - IAQUIN LOCAL HEALTH DT --4ICT <br /> Mfh A STORAGE TANK PR06.RAM FARM TANK ItlFnen FORM <br /> FACILITY/BITE INFORMATION (Coeplete this Fon for each FARM TANK location) <br /> ICADDRKESS <br /> RM or BUSINESS NAME pt(/&a , <br /> eY aY tsb(S reek address of TANK location)H TY STATE t[P CODE <br /> - <br /> CMEBK MERE if this At <br /> should be used for Legal Notification <br /> OPERATOR INFORMATION 1 ADDRESS (Complete if Information Different frog Above) <br /> NAME + OPERATOR CONTACT NAME <br /> IFS#\PM d <br /> ' c <br /> ER MAILING or STREET ADDRESS J Q 1�9 OPERATOR PHONE 1 WITH ^AKA COOK <br /> 0 CITY f Ff mvr; q(tE T?1FEODE <br /> R <br /> CMECK MERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OMER INFORMATION & ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE a WITH AREA COOK <br /> W <br /> N <br /> E <br /> R CITY STATE ZIP CODE <br /> - CMECK SERE if this ADDRESS should be used for Legal Notification <br /> Checl Appropriate Box <br /> T ACTIVE FARM TANK SITE (One or mon underground TANKS ) 1,100 gal. capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site • to or ( 1,100 gal. capacity) <br /> E <br /> PERMANENTLY 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 /> r— <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 /> I <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 Q TITLE DATE <br /> OFFICE MSE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE D ACTIVE U61 t EXEMPT UGT 1 CLOSED U6T SWEEPS PREM/SUB CODE DATE71 <br /> EH 23 044 (12/88) <br />