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Underground Storage Tank Program - Farm Tank Information Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACI'NAME <br /> A F Dennis Michaels <br /> C ADDRESS(Street address of TANK location) PI IONE Y (with arca code) <br /> 1 2720 E. Acampo Rd. ( 209) 369-2523 <br /> L <br /> 1CITY STATE I ZIP CODE I NIAItTST CROSS S REEL' <br /> 1, Acampo CA 95220 Sycamore St . <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete If Information different from above.) <br /> 0 NAME OPERATORCONTACI'NAME <br /> P Jeryl R. Fry , Jr . Dennis Michaels <br /> E MAILING or STREET ADDRESS OPERATOR PI IONS 0 (with area code) <br /> R 12609 No . West Lane (209) 334-3808 <br /> A <br /> T CITY SPATE I "LIP CODI; <br /> 0 Lodi CA 95240 <br /> R gg CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME OWNl R CONTACT'NAMN. <br /> O same as above <br /> NMAILING or STREET ADDRESS OWNER PHONE Y(with arca code) <br /> E <br /> R CITY STATE I ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> ,1, ACr VE FARMTANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground'rANKS 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 /> KX ( 6 P' ) <br /> UNDERGROUND TANK INFORMATION (List additional tank information on separate sheet If needed.) <br /> T TANK SIZE CHEMICALS STORED ESTIMATED DATE LAST USLO mf:nioD OF CI.QSURE DATE OI'REMOVAL OR <br /> A (OALIDNS) CURRENTLY OR PRLVIOUSLY IF CUIUIENILY EMPTY IF PERMANEN MY CIJISED c[MUw(IN PIACh <br /> N <br /> K 250 Diesel pre-1989 Removed pre-1989 <br /> 1 250 Diesel pre-1989 Removed pre-1989 <br /> N <br /> F <br /> O <br /> THUS FORM FLU BEEN COMPL.KrED UNDER PENALTY OF PERJURY,AND TO TTIE'aFST OF MY KNOWLEDGE,IS T RUR ANU CORREVI'. <br /> NAME TITLE Controller DAlii 08/22/89 <br /> OFFICE USE ONLY <br /> SWISPSY COMP 1 IAC CODEULSTCODEY ACI1VEUG'I' YEXEMPT UGI NCLWLD U61 SWELIs PRGM/SUU cGOE uA'lli <br />