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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FARM TANK INFORMATION FORM <br /> FACILITY/SITE INFORMATION (Complete this Form for each facility/site) <br /> ARM or BUSINESS NAME CONTACT NAME ' <br /> Estate of Louis DeLuca 0ava Devine <br /> i DDRESS (Street address of TANK lgcation) 1.; , . HONE p WITH AREA CODE - <br /> ` 14248 E : Pal-et-lec Road 209-727-5864 <br /> ITY TATE IP CODE :' EAREST CROSS STREET 11 <br /> 1. <br /> Acambo CA'' 55220 Jacktone <br /> HECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION B ADDRESS (Complete if Information Different.from Above) <br /> AMEOPERATOR CONTACT NAME <br /> AILING or STREET ADDRESS OPERATOR PHONE # WITH AREA CODE <br /> ITY . TATE IP CODE <br /> r <br /> HECK HERE if this ADDRESS should be Used for Legal.Notification <br /> f: PROPERTY OWNER INFORMATION 9 ADDRESS (Co!!plete if Different from Above) r <br /> AME WNER CONTACT NAME <br /> EBteta lif .Dsue 'DeLutie. Oav Devine ' <br /> AILING or STREET INFORMATION -'r• ' -:5 . "'` tR!F-R P!In!!c f( WITH AREA CODE <br /> 0. 0 . .86X 316 209-727-5864 <br /> ITY iR TATE IP CODE <br /> Lookford CA 95207 ' <br /> X HECK,HERE if this ADDRESS should be used for Legal Notification <br /> Check Appropriate Box - <br /> (One or more underground TANKS > .1,100 gal. capacity) <br /> kT IVE FARM TAN <br /> K SITE - <br /> r` XEMPT FARM TANK SITE (ALL underground TANKS at site to or < 1,100 gal. capacity) <br /> Xf ERMANENTLY 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 /> TANK SIZE ? CHEMICALS STORED ` - STIMATED DATE LAST USED ' MEHTOD OF CLOSURE . DATE OF REMOVAL OR <br /> (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> 1000 Gasoline11/92 Removal 1 /9.11 <br /> 1000 Gasoline ' "' 11/92 Removbl 1/93 <br /> r <br /> 1000 Diesel 11/92 ARMOVAI 1/�3 <br /> TH FORM HAS 92N COMPL TED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> AM ITLF ATE <br /> 1-6-93 <br /> OF ICE USE ONLY <br /> WEEPS k OMP ff LOC CODE DIST C�ODE� N ACTIVE UGT H EXPEMT UGT d CLOSED LOT SWEEPS PRGM/SUB CODE DATE <br /> All <br /> EH 23 044 10/89 1p <br />