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Underground StorafTank Program - Farm Tank formation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F Ken <br /> A Kenneth Kang Inc . <br /> C ADDRESS(Street address of TANK location) YIfONE q (with area coda) <br /> 111 Ave. 209 599-2238 <br /> L 20137 E. <br /> I CITY STATE 2UP CO�NFARRSTCROSS S1REGI' <br /> T Ripon Calif. 95366 Ave. <br /> Y I <br /> y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS /Complete if information different from ubove.) <br /> 0FMAILING <br /> E OPERKI'OR CONTACT NAME <br /> P <br /> E or STREET ADDRESS OPERATOR PI ith area code) <br /> R <br /> A S1'A'1'E LIP CODE < L yG �� <br /> 0 <br /> R CHECK HERE is this ADDRESS should be used for Legal Notification. ? �?� <br /> PROPERTY OWNER INFORMATION &ADDRrSS (Complete If different from above.) pLl y <br /> NAME OWNER CONTACT <br /> 0 <br /> W MAILING or STREET ADDRESS OWNER PHONE q(with area code) <br /> N <br /> E <br /> R CITY STATE LIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CIIECK APPROPRIATE BOX <br /> ,1, AC1M FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P X EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> E 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 TANKSIZE CJIP.MICAL.SSTORF.D FSTIMA"TED DATE LAST USED MGI NOD OF CLOSURE DA'I'S OF REMOVAL OIL <br /> A (QAL LONS) CURRENTLY OR PREVIOUSLY IF CURR.EWLY r—MPI'Y IF PERMANEN'MY CWSED CL.OSURI:IN NACH <br /> N <br /> K 500 Gas <br /> I <br /> N <br /> F <br /> 0 <br /> "US FORM IL1S BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO771E BEST OF MY KNOWLEDGE,IS TRUE AND CORHEICE <br /> NAME L� TITLE Owner DATEAug. 14, 198 <br /> OFFICE USE ONLY <br /> SWIiM# I OOMPO LOC:CODL' DLSTCODEgACI1VLUG'L' I gIJCEMP7'UG'I' oCLOSEUUG'1SWEEI'SPUGM/SUUCODU UA'lli <br /> El-I 23 044(12/88) <br />