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" < ' Underground St1mge Tank Program - Farm Ta 1wformatio m ' <br /> IfACII,I'I'YISI'I'L'INFOItMA'I'ION Com let <br /> ( I' a this dorm For each FARM TANK location.) rn �� <br /> FARM or BUSINESS NAME <br /> CONTACT NAM <br /> AGeorge B. Lagorio Farms George B. La io — �> <br /> C ADDRFSS(Street address of TANK location) — <br /> I PHONE# (with area„ de) ti <br /> 5458 E. Section (209) 982-073�N � <br /> on <br /> 1 CITY C/3 Ric <br /> STATE ZIP COOL; NEAREST'CROSS STREET' <br /> T Stockton Z <br /> Ga 95205 Walker Lane <br /> Y Cl it CK I Il Rls if This ADDRESS should he used for Legal Notification <br /> 011ERA'rOR INFORMA'T'ION &ADDRESS (Complete if information different from above,) <br /> O NAMI. OPERATOR CONTACT NAME <br /> P <br /> E MA11_1NG or STREET ADDRESS <br /> R OPERATOR PHONE# (with area code) <br /> A <br /> T CITY S'I"ATTs ZIP CODE <br /> O <br /> R CIIFCK FIERE is this ADDRESS should he used for Legal Notification. <br /> I'ROPE,RTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME <br /> fl <br /> OWNER CONTACT NAME <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E <br /> R CITY Y S"FATE ZIP CODE <br /> C!IECK III R1 if this ADDRI ,SS should he used for Legal Notification <br /> CHECK AI'I'R01'RIATE BOX <br /> .T. X ACTIVE FARM TANK SITE, (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE; (ALI,underground TANKS at site = to or < 1,100 gallon capacity) <br /> E PEAMANI NT�LY CLOOSI D FARM TANK SITE (ALL underground TANKS at site removed or closed in place) <br /> tJNDI?Itf:ItOtIND TANK INfOItMA'I'ION (List additional tank information on separate street if needed.) <br /> T (GAL SI S' ClifiMICATS sTOltl:D ESTIMATED DA11s LAST 11SED Ml n ioD OF C1A5tlRE DATT,OF REMOVAL OR <br /> A (C.Al.1.r)NS) CURRENTLY Olt PRI;VIOUSLY IPCl1R1tI N1'I.Y I M!''!'Y 11'PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K 8000 Unleaded Fuel <br /> 1 8000 Diesel Fuel <br /> N <br /> F <br /> fl 1 <br /> 'fills FOR IIV1, INSI N COMP[ :ITsI UNDER PENALTY OI'ITPLIURY,AND`l'O TMS ISENT Ola MY KNOWLCDGF,,IS TRU[:AND CORRECT. <br /> N I " 1V* TITLE Owner DATE 9/22/89 <br /> OFhICE,USE ONLYI, <br /> SWFEII'S# COMP# LOC CODI; DIST CODE; #AC'r1Vli 1JGT #1?hliMP'I'UGI' #CLOSED UGT SWEEPS PRGM/5U11 CODE DATE <br /> I"If 23 044(12/98) <br />