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SANOAQIJIN LOCAL HEALTH AIICT <br /> AR <br /> UNDERGROUND STORAGE TANK PROGRAM - FARA-TANKINFORtlT g FORM <br /> _ <br /> FACILITY/81TE INFORMATION (Complete this Fore for each FARM TANK location) S Zr' <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F I C IC / O t e <br /> A <br /> C ADDRESS (Street address of TANK locatio6 9E 1 WITH ARCA coag / C <br /> L 811 Presidents Circle Z� � ' � Jyl <br /> _Ty T ST EEf CITY NRY � CS <br /> CNECX HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION 4 ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE I WITH AREA coat <br /> R <br /> A <br /> T <br /> 0 CITY STATE i1P CODE <br /> R <br /> CNECX UEAE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION N ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> UNIVERSITY OF THE PACIFIC Scott Heaton <br /> O MAILING or STREET ADDRESS OWNER PHONE 1 WITH ARCA CODE <br /> N 1081 W. Mendocino Ave. (209) 946-2541 <br /> E <br /> R CITY Stockton , CATE ZIP <br /> 9F,9UE1ll <br /> X CNECX HERE if this ADDRESS should be used for Legal 6yNootification <br /> CAect A//ro/riate Box <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS ) 1,100 gal. capacity) <br /> Y <br /> P X EXEMPT�I TANK SITE !� (ALL underground TANKS at site a 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 SIIE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE Of REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY If CURRENTLY EMPTY I PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N- <br /> K <br /> N <br /> F <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY Of PERJURY, AND TO THE BEST Of MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME TITLE W41-7-)() DATE y <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE11 ACTIVE UGT 1 EXEMPT UGT 1 CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 (12/88) <br />