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SAN J QUIN LOCAL HEALTH DIS—'ICT <br />QNpERGROUT(TSTORAGE TANK PROGRAM FAIN TANK INFORMAT VffnRM <br />FACILITYISITE INFORMATION (Coeplete thle For& for each FARM TANK location) <br />FARM or BUSINESS NAME <br />NAME <br />CONTACT NAMES <br />0 :h ��JJ <br />F o Pl <br />U SG <br />q�1c ✓( <br />��ollPy <br />/5C <br />A <br />SD P� e <br />MAILING or STREET ADDRES'S Mj�'{ j <br />R <br />( �y�� <br />OPERATOR PHONE 1 ""M " or <br />"c/ <br />C ADDRESS (Street address <br />of TANK location) <br />R <br />PHONE I " "M ""C" Cnna <br />iJli•.1, 11LALTiI <br />I <br />0 CITY <br />/S— l� <br />i/eG <br />M CE RETE if this ADDRESS show d be used for Legal Notification \ <br />T CITY <br />Y <br />g, <br />STATE <br />IIP CODE <br />NEAREST CkOSS STREET <br />Legal Notification he <br />D C <br />CZ <br />SOZ y6 <br />CHECK HERE if this <br />ADDRESS should be <br />used for Legal Notification <br />OPERATOR INFORMATION I ADDRESS (Coeplete if Inforeatlon Different fro& Above) <br />NAME �r+�(J <br />NAME <br />OWNE rCf NAME <br />OPERATOR CONTACT NAME <br />0 :h ��JJ <br />0 R PHONE'4 "'Q^"�" 4Ooe V <br />e <br />N <br />PERIIANEMILY CLOSED FARM TANK SITE (ALL underground TANKS at site resoved or closed in place) <br />P <br />CLOSURE IN PLACE <br />Kt2, 00C' <br />SD P� e <br />MAILING or STREET ADDRES'S Mj�'{ j <br />R <br />( �y�� <br />OPERATOR PHONE 1 ""M " or <br />"c/ <br />R <br />A <br />iJli•.1, 11LALTiI <br />- <br />0 CITY <br />/S— l� <br />i/eG <br />M CE RETE if this ADDRESS show d be used for Legal Notification \ <br />Q <br />g, <br />CRF I YEIE if this ADDRESS should be used for <br />Legal Notification he <br />PROPERTY OWNER INFORMATION I ADDRESS (Complete if Different (roe Above) q� U n. 0 <br />Check AAAroprfale 341 " 11�- ) 0 \w <br />Y <br />NAME <br />OWNE rCf NAME <br />0 <br />N <br />MAILING or STREET AD SS <br />0 R PHONE'4 "'Q^"�" 4Ooe V <br />e <br />N <br />PERIIANEMILY CLOSED FARM TANK SITE (ALL underground TANKS at site resoved or closed in place) <br />IF PERMANENTLY CLOSED <br />CLOSURE IN PLACE <br />Kt2, 00C' <br />SD P� e <br />E <br />P7Jlov2 <br />f / 9 <br />R <br />CITY <br />STAIE <br />)IP CODE <br />N / <br />/S— l� <br />i/eG <br />M CE RETE if this ADDRESS show d be used for Legal Notification \ <br />Check AAAroprfale 341 " 11�- ) 0 \w <br />Y <br />ACTIVE FARM TANK SITE (One or &ore underground TANKS ) 1,130 gal. capacity) <br />P <br />E <br />EXEMPT FARM TANK SITE (ALL underground TANKS at site • to or ( 1,100 gal. ca city) <br />DATE OF REMOVAL OR <br />A (GALLONS) <br />N <br />CURRENTLY OR PREVIOUSLY <br />PERIIANEMILY CLOSED FARM TANK SITE (ALL underground TANKS at site resoved or closed in place) <br />UNDERGROUND TANK INFORMATION fLisl Additional tank inforeation on separate sheet if needed) <br />I TANK. SII[ <br />CHEMICALS STORED <br />ESTIMATED DATE LAST USED <br />METHOD Of CLOSURE <br />DATE OF REMOVAL OR <br />A (GALLONS) <br />N <br />CURRENTLY OR PREVIOUSLY <br />If CURRENTLY EMPTY <br />IF PERMANENTLY CLOSED <br />CLOSURE IN PLACE <br />Kt2, 00C' <br />SD P� e <br />/,j- r!S <br />P7Jlov2 <br />f / 9 <br />/ <br />r0`/JUC� <br />Pse <br />/S— l� <br />i/eG <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PER URY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />NAME TITLE OA TE <br />J` �4 <br />Off ICE USE OILY <br />SWEEPS I COMP 1 LOC CODE DIST CODE 1 ACTIVE UGl 1 EXEMPT UGI 1 CLOSED UGT SWEEPS PRGM/SU8 CODE DATE <br />EH 23 044 (12I08) <br />