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1� Underground StoraeCank Program - Farm Tank Iwmation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> A Vander Meulen & ➢irksen Inc . Pete Vander Meulen <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> 1 29756 Orange Avenue 209-838-3731 <br /> L <br /> I CITY STATE I ZIP CODE NEAREST CROSS STREET <br /> T Escalon CA 95320 Henry Road <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete if information different from above.) <br /> 0 NAME OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> R <br /> A <br /> T CITY STATE I ZIP CODE <br /> O <br /> R CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) <br /> NAME / OWNER CONTACT NAME <br /> O Laura Dirksen <br /> N MAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E same 209-838-7434 <br /> R CITY STATE I ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> ,1, ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y EXEMPT FARM TANK SITE ( g g capacity) <br /> P ALL under round TANKS at site = to or < 1,100 gallon ca acit <br /> E X 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 /> 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 /> K 5000 diesel fuel April 30 Removed 6/28/89 <br /> 1 /4500 diesel fuel April 30 Removed 6/28/89 <br /> N 300 gasoline April 30 Removed 6/28/89 <br /> F <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TTIt BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> i <br /> NAME i, i,�9. , f� TITLE DATE <br /> OFFICE USE ONLY <br /> SWEEPS# COMP# I LOC CODE DIST CODE#ACTIVE UGT I#EXEMPTUGT I#CLOSED UGT I SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044(12/88) <br />