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Underground Stora!e Tank Program - Farm Tank-rormation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONI'ACI'NAME <br /> A DELL'OSSO FARMS EUDv DELL'OSSO <br /> C ADDRESS(Street address of TANK location) PRONE N (with area code) <br /> 1 26 WEST STEWART ROAD — LAT_ HROP, CALIF. 95330 (209) 982-0833 <br /> L <br /> I CITY STATE I ZIP CODE I NEAREST CROSS S'1REEI' <br /> T LATHROP CA. 95330 MANTHEv ROAD <br /> Y CHECK HERE if this ADDRFSS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete If information different from above.) <br /> O NAME OPERATORCONTACI'NAME <br /> P _ <br /> E MAiI.INGorMFETADDRESS OPERATORPiIONFN (wishareacode) <br /> R <br /> A <br /> T CITY STATE ZIP CODE <br /> O <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 /> O <br /> NMAILING or STREET ADDRESS OWNER PHONE B(with area code) <br /> E <br /> R CI'T'Y STATE ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CIIECK APPROPRIATE BOX <br /> .I. ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> E Y TIPERMANENTLY CLOSED FARM TANK SITE (A .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 MEII IOD OF CLOSURE DA'Z'E OF REMOVAL Olt <br /> A (GALLONS) CURREN'ILYORPREVIOUSLY IF CURRENILY EMPTY IF PERMANEFI"ILY CLOSED CLOSURl'.IN 1'IACU <br /> N <br /> K 2,000 UNLEADED GASOLINE 5-15-89 REMOVED 5-18-89 <br /> LI <br /> N <br /> F <br /> 0 <br /> /TIUS FORM RAS BEEN COMPL91TD UNDER PENALTY OF NEW URY,ANDTO TILE BESTOF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAMA' f�e�P��Yj�i(� 'ITfLE FARM OWNER DATE 9-22-89 <br /> OFFICE USE ONLY <br /> a lb W[iEP511 COI�IPM LCCCODE DISTCODESACIIVEUO`I' I aEXf-NPT'UG'IMCL.USEDUC'1' SWEEI'SPIwM/SUOCODE UA'1'li <br /> (�EH 23 044(14/88) <br />