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Underground Stcye Tank Program - Farm TalaWformation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> I'ARM or BUSINESS NAME _ � CONTACT NAME <br /> C ADDRESS(Street address of TANK location) PIIONE i a <br /> ;IVFr) <br /> L - <br /> Fff <br /> I CITY STATE ZIP CODE NEARESTCROSS STREET' <br /> T J U L 11 190 <br /> Y CHECK HERE if this ADDRESS should be used for Legal NotificationIq ENVIRONMENTAL NEK F. <br /> PtRMITI"J V <br /> OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) <br /> O NAME OPERATOR CONTACT'NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE N (with area code) <br /> R <br /> A <br /> T CITY STATE I ZIP CODE <br /> O <br /> R �—FcIIECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME VNER CONTACT NAME <br /> O ee'' <br /> NMAILING or STREET A 4gy1 M Uz lz� VNER PHONE N(with area code) <br /> E 0 �-M <br /> R CITY <br /> SINCE1141 r <br /> CHECK Flf?RE it ���+�CH y� <br /> FARMING • LIVESTOCK <br /> 9251 So.Wolf Road French Camp,Calif.95231 <br /> CIIECK APPROPRIATE Phone(209)982.1482 <br /> ,I, ACTIVE FARM' ��.., ,. 'TANK.S > 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 C PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed flrr _ . <br /> UNDERGROUND TANK INFORMATION (List additional tank information on separate sheet If needed.) <br /> T TANKSIZE CHEMICALS STORED ESTIMAT10 DA'Z'E LAST USED METHOD OF CLOSURE DATE OF ItEMOV - <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IFCURREMILY EMPTY IF PERMANENTLY CLOSED iCE <br /> N p n <br /> K fly /,' Dl.; 1) F:'f MA ' <br /> I <br /> N <br /> F <br /> 0 <br /> THIS FORM IMS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE:,IS TRUE AND CORRECT. <br /> NAME DATE <br /> OFI�ICF,USF NI,Y <br /> SWEET'S N DUMP N IAC CODE I DIST CODEN AC-FIVE UGI' N EXLMP'l Wl' N CLOSED WT I SWPJ--PS PRGM/SUI3 CODE DATE. <br /> EI 123 044(12/hg) <br />