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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE <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 ONTACT NAME <br /> Estate of Louis DeLuca Dave Devine <br /> I DORESS (Street address of TANK Location) - HONE # WITH AREA CODE <br /> I 1424B E . Peletier Road 209-727-5864 <br /> ITY TATE I CODE EAREST CROSS STREET <br /> Acamoo CA95220 Jacktone <br /> HECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION & ADDRESS (Complete if Information Different from Above) <br /> AME OPERATOR CONTACT NAME <br /> AILING or STREET ADDRESS OPERATOR PHONE # WITH AREA CODE <br /> ITY TATE IP CODE <br /> HECK HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION & ADDRESS (Complete if Different from Above) <br /> AME /'`11L WNER CONTACT NAME <br /> Estate of Dz. a DeLuca Dave Devine <br /> AILING or STREET INFORMATION - WNER PHONE # WITH AREA CODE <br /> P . O . Box 316 209-727-5864 <br /> :TTY TATE IP CODE <br /> Lockford CA 95237 <br /> X HECK, HERE if this ADDRESS should be used for Legal Notification <br /> Check Appropriate Box <br /> CTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gal. capacity) <br /> XEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gal. capacity) <br /> X. 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 Gasoline 11192 Removal 1/92 <br /> 1000 Gasoline 11/92 Removal 1/93 <br /> 1000 Diesel 11/ 92 <br /> IN FORM HAS BEEN COMPL TED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> AIA ITLE�G _ C�'�2 ATE <br /> � 1-6-93 <br /> OF ICE USE ONLY <br /> WEEPS # OMP # LOC CODE DIST CODE # ACTIVE UGT # EXPEMT UGT # CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 10/89 <br />