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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <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 <br /> ONTACT NAME ,p,,�/ <br /> 1 DDRESS (Street address o TANK location) I Id — ( " — <br /> NONE # WITH AREA CODE <br /> 1 C5l S <br /> ITY <br /> TATE IF CODE EARE ST CROSS STREET <br /> HECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION & ADDRESS (Complete if Information Different from Above) <br /> AME <br /> PERATOR CONTACT NAME <br /> ,z � T- <br /> ILING or STREET ADDRESS <br /> PERATOR PHONE # WITH AREA CODE <br /> ITY <br /> TATE IP CODE <br /> HECK HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION & ADDRESS (Complete if Different from Above) <br /> AME <br /> WNER CONTACT NAME <br /> \._ AILING or STREET INFORMATION WITH AREA C <br /> WNER PHONE # ODE <br /> ITY TATE IF CODE <br /> NECK HERE if this ADDRESS should be used for Legal Notification <br /> Check Appropriate Box <br /> CTIVE FARM TANK SITE (One or more Underground TANKS > 1,100 gal, capacity) <br /> EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 <br /> 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 /> L <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> AME ITLE <br /> J ATE <br /> OFFICE USE ONLY <br /> WEEPS # OMP # LOC CODE DIST CODE # ACTIVE UGT # EXPEMT UST # CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 10/89 <br />