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SAN JD QUIN LOCAL HEALTH DIST CT <br /> UNDERGROUWDRAGE TANK PROGRAM - FARM TANK INFORMATION <br /> FACILITY/BITE INFORMATION (Complete this Fore for each FARM TANK location) <br /> FARM or BUSINESS NAME I CONTACT NAME <br /> A G?//4 � �. ' c l / s <br /> C ADDRESS (Street address of TANK location) PHONE 1 WITH AREA CODE <br /> T CITY/ STATE 21P CODE NEAREST CROSS STREET III' <br /> Y L v <br /> CHECK HIRE if this ADDRESS should be used for Legal Notification 89 <br /> OPERATOR INFORMATION i ADDRESS (Complete if Information Different from Above) ENb'iRONp,ENiAL H= H <br /> NAME-7— OPERATOR CONTACT NAME ES <br /> P �. C 6 - <br /> E MAILING or STREET ADDRESS OPERATOR PHONE I WITH ARCA CODE <br /> R j <br /> T <br /> 0 CITY / STATE IIP CODE <br /> "Z <br /> R % <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION 1 ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITH AREA COOK <br /> W <br /> N <br /> E <br /> R CITY STATE ilP CODE <br /> CHECK NERE if this ADDRESS should be used for Legal Notification <br /> Chect Appropriate Box <br /> I 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 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 /> N (GALLONS) CURRENT OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED COSURE IN PLACE <br /> 1 <br /> N <br /> F <br /> 0 <br /> THIS FM HAS BEEN COMPLETED UNDER PENA4TY Or PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME TITLE OA TE <br /> or I Usr ON <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE 1 ACTIVE UGT 1 EXEMPT UGT 1 CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 (12/88) <br />