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SAN J. 01.1IN LOCAL HEALTH D1Sl,Ww:CT <br /> UNDERGROUND STORAGE TANK PROGRAM - FARM TANK INFORMATION FORM <br /> FACILITY/BITE INFORMATION (Complete thle Fon for mach FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F 1FMAS FARMS LEROY E METTLER <br /> A <br /> C ADDRESS (Street address of TANK location) PHONE 1 WITH "«g" coag <br /> L 13939 N ALPINE RD. (209) 334-2951/369-8524 <br /> 1 <br /> T CITY STATE LIP CODE NEAREST CROSS STREET <br /> Y LODI CA 1 95240 1 HARNEY LN. <br /> CBECI Nfff if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION i ADDRESS (Complete If Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 LEMAS FARMS LEROY E METTLER <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 WITH "aE" CODE <br /> A /(OXO 14090 If ALPINE RD. (209) 334-2951 / 369' 524'` <br /> r <br /> 0 CITY STATE klP CODE <br /> [!��LLJODI CA 5240 <br /> RE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION IT ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE i WITH Aft" CODE <br /> W <br /> N <br /> E <br /> R CITY STATE LIP CODE <br /> CNECE HERE if this ADDRESS should be used for Legal Notification <br /> Chect JpPro/riafe Box <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS ) 1,100 gal. capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site to or ( 1,100 gal. capacity) <br /> L.E <br /> x JPERMANENJLY 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 SITE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD Of CLOSURE DATE Of REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K 3,000 DIESEL MAR. 1988 <br /> 1 <br /> 2,000 GAS MAR. 1988 <br /> N <br /> F <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY DF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME TITLE OWNER OATS 6/27,(89 <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE 1 ACTIVE UGT 1 EXEMPT UGT 1 CLOSED UGT SWEEPS PRGM/SUB CODE I DATE <br /> '':T,, n;\3 <br /> EH 23 044 (12/88) <br />