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SAN JOAQUIN LOCAL HEALTH DIST ICT <br /> UNDERGROOTORAGE TANK PROGRAM - FARM TANK INrI RN O C T 3 O 1989 <br /> FACILITY/SITE INFORMATION (Complete thie Form for muh FARM TANK location) ENVIRONMENTAL HEALTr-i <br /> FARM or BUSINESS NAME CONTACT NAME <br /> A U1�1 leo ASU Pl--� <br /> C ADDRESS (Street address of TANK location) PHONE 1 WITH AAKA COOK <br /> T CITY STATE IIP CODE NEAREST CROSS STREET <br /> � r-- oS A <br /> CHECK HERE it I h i s ADDRESS should be used for Legal Notification f 2,-X 41C3L <br /> OPERATOR INFORMATION i ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE I WITH ARCA COKE <br /> R <br /> A <br /> T <br /> 0 CITY STATE 111 CODE <br /> R <br /> [HECL 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 ARCA COOK <br /> W <br /> N <br /> E <br /> R CITY STATE I1P CODE <br /> [HECL HERE if this ADDRESS should be used for Legal Notification <br /> Check Appropriate box <br /> T ACTIVE FARM TANK SITE (One or bore underground TANKS ) 1,100 gal. capacity) <br /> Y <br /> E EXEMPT FARM TANK SITE (ALL underground TANKS at site R to or ( 11100 gal. capacity) <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 SIZE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> N <br /> F <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME f TITLE DATE <br /> OFF I[ USE ONLY <br /> SWEEPS 1 CONP 1 LOC CODE DIST CODE11 ACTIVE UGT 1 EXEMPT UGI 1 CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 (12/88) <br />