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0 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE <br /> UNDERGROUND STORAGE TANK PROGRAM - FARM TANK INFORMATION FORM <br /> FACILITY/SITE INFORMATION (Complete this Form for each facility/site) <br /> ARM or BUSINESS NAME CONTACT NAME <br /> ate✓ �/�'e— t3h /O.v <br /> 1kDDRESS <br /> (Street address of TANK location) HONNE/J# WITH AREA CODES <br /> / ✓ U�J s QTY I' �'� c:_ 7 ( <br /> ITY ( TATE IP CODE JAREST CROSS STpEEj <br /> NECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION 8 ADDRESS (Complete if Information Different from Above) <br /> AME OPERATOR CONTACT NAME <br /> (LING or STREET ADDRESS OPERATOR PHONE # WITH AREA CODE <br /> ITY TATE IP CODE <br /> HECK HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION 8 ADDRESS (Complete if Different from Above) <br /> AME WNER CONTACT NAME <br /> (LING or STREET INFORMATION WNER PHONE # WITH AREA CODE <br /> ITY TATE IP CODE <br /> HECK HERE if this ADDRESS should be used for Legal Notification <br /> Check Appropriate Box <br /> CTIVE FARM TANK SITE (One or more underground TANKS > 11100 gal. capacity) <br /> XEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gal. capacity) <br /> ERMANENTLY 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 /> TANK SIZE CHEMICALS STORED STIMATED DATE LAST USED MEHTOD OF CLOSURE DATE OF REMOVAL OR <br /> (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> THIS FORM HAS BEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> AME ITLE ATE <br /> S d X? /;7� <br /> -- OFFIC SE ONLY <br /> WEEPS # OMP # LOC CODE I DIST CODE # ACTIVE LET # EXPEMT UGT I # CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 10/89 <br />