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S JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDER6ROI�STORA6E TANK PROGRAM - FARM TANK INFORMATI�DRN <br /> FACILITY/BITE INFDRMA ON (Complete thle Fore for uch FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> A C� e C <br /> C ADDRESS (Street address of.TANK location) PHONE) WITH AREA Cucc <br /> 1 09 <br /> T CITY STATE 21P CODE ME X CROSS STREET <br /> ENECI 8ERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION It ADDRESS (Complete if Inforaation Different froa Above) <br /> NAME OPERATOR CONTACT NAME <br /> D Q.J -e 10C e C <br /> P <br /> EMAILING or STREET ADDRESS OPERATOR PHONE 1 WITH AREA Cmmi <br /> R ✓ f s9 <br /> T <br /> 0 CITY /1 ISIATE IIP CODE <br /> R <br /> CBECI HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION i ADDRESS (Coeplete if Different (rot Above) <br /> NAME r OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE t WITH AREA Cnof <br /> W <br /> N <br /> E <br /> R CITY STATE ZIP CODE <br /> CBECI NERE if this ADDRESS should be used for Legal Notification <br /> Chea Appopriate box <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 Additinr.a! tact 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 /> K o2 c� G wr u ule F-gy <br /> 1 <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 r TITLE DA1 <br /> I G �yz-lo <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE[I ACTIVE UGI t EIEMPT UGT 1 CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 (12/88) <br />