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Underground Store Tank Program - Farm Tank0formation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> IFARM or BUSINESS NAME CONTACT NAME <br /> -1'I t <br /> ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> , S Q �4 <br /> STATE ZIP CODE NEAREST CROSS STREET <br /> CITY <br /> M n cC� CA 33 <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete if information different from above.) <br /> O <br /> NAME OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> R <br /> T CITY STATE ZIP CODE <br /> 0 <br /> R CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME OWN ER CONTACT NAME <br /> 0 <br /> W MAILING or STREET ADDRESS OWNER PHONE N(with area code) <br /> N <br /> E <br /> R CITY STATE ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> ,l, ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> P <br /> E X 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 /> K 1100ioc Diesel / yCAsolLne taken GUt a V) <br /> I <br /> N <br /> F <br /> 0 <br /> TEAS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME R TITLE O DATE 7- <br /> OFFICE USE ONLY <br /> SWEEPS# I COMP# IOC CODE DIST CODE#ACI'IVE UGf I#EXEMPT UGf #CLOSED UG'f SWEEPS PRGMiSUB COUE DATE <br /> EH 23 044(12/88) <br />