Laserfiche WebLink
# SAN WOUIN LOCAL HEALTH DI CT <br /> h' R R U ORA N PROGRAM f T 4 -' <br /> FACILITY/SITE INFORMATION (Complete this Fore for each FARM TANK location) 3 Z 4, <br /> FARM or BUSINESS NAME CONTACT NAME J <br /> F L . C3cv(A\' A� <br /> C ADDRESS (Street address of TANK location) PHONE IP WITH AR[A COOK i . /SERVICES <br /> L J Z94S4- Lash <br /> I <br /> T CITY `S C L®W• STATE ZIP CODE NEAREST CROSS STREET <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION 1 ADDRESS (Complete if Information Oifferunt from Above) <br /> NAME C C�e 11 fQ OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE I WITH ANCA CODE <br /> R <br /> A <br /> 0 CITY STATE IIP CO--[ <br /> DE <br /> k <br /> X' CHECE HERE if this ADDRESS should be used for legal Notification <br /> PROPERTY OWNER INFORMATION I ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITH AREA coda <br /> W <br /> N <br /> E <br /> STA <br /> R CITY TE IIP CODE <br /> CHECK HERE if this ADDRESS should be used for legal Notification <br /> Checl Appropriate 14X <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gal. capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or ( 1,100 gal. capacity) <br /> E <br /> 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 S!IE CuEN1f.gLS cTOocD CCTIMATED DATE LAST USED METHOD OF CLAC.InESED DATE OF-P,EMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY If CURRENTLY EMPTY IF PERMANENTLY CLOCLOSURtIf`1 PEACE <br /> N <br /> I <br /> N <br /> F <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY 0 PERJURY, AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT <br /> NAME TITLE �,W IV DATE <br /> q-- � �89 <br /> OIFICE USE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE11 ACTIVE UGT 1 EXEMPT UGT 1 CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> LrH 23 044 (12/88) <br />