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SAN J 1AQOIN LOCAL HEALTFI DISTRICT <br /> OR f TANK PROGRAM - I(A�tM TANK INFORMAf`ORM <br /> FACILITY/91TE INFORMATION (Complete thio Fon for each FARM TANK location) HEATING OIL TANK <br /> FARM or BUSINESS NAME CONTACT NAME <br /> A HEUBLEIN WINES <br /> C ADDRESS (Street address of TANK location) PRONE t WITH AREA Con. <br /> I <br /> L 21801 Hwy 120 <br /> Y CITSCALON STATE ZIP CODE NEAREST CROSS STREET <br /> CA 95320 <br /> X CHECK #ERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION 0 ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 WITH AREA CCmm <br /> R <br /> A <br /> I <br /> 0 CITY SfA1ELNotification <br /> RCNECR HERE it this ADDRESS should6e used for <br /> PROPERTY OWNER INFORMATION I ADDRESS (Complete If Different from Above) <br /> NAME_ �j T OWNER CONTACT NAME I <br /> 1^ 1)1C�LCq l C"S I iUL c �0 o^ C cC)1Ml1S' <br /> O MA IL IN6 ar S REET ADDRESS OWNER PHONE 1 WITH •Rill CCmi <br /> u <br /> N 7 <br /> F ( �i 11 �f S C — 1 <br /> R CITY SIA1E ZIP CODE <br /> _ C <br /> CNECR RE if this ADDRESS should be used for Legal Notification <br /> CAeof Appropriate Box <br /> flMIRKANENTLY <br /> ACTIVE FARM TANK SIZE (One or more underground TANKS > 1,100 gal. capacity) <br /> EXEMPT (ARM TANK SITE (ALL underground TANKS at site • to or ( 1,100 gal. capacity) <br /> CLOSER (ARM 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 /> I TANK SIZE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY <br /> N IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> K 550 diesel fuel Unknown <br /> tank removal 12/24/92 <br /> T <br /> N <br /> f <br /> 0 <br /> THIS FO COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME <br /> ruC RL `xlcz <br /> ITLE nn,,�� DATE <br /> x <br /> !Cf USE` MLY <br /> SWEEPS 1 COM LOC CODE DIST CODE t ACTIVE UGT 1 EXEMPT UGI 1 CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 (121gB) <br />