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Underground Stege Tank Program - Farm Tar�Wormation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> A Fi6he2 NuA6eAy, Inc. ae¢izy 7i6he2 / B2ad Boom <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> 1 24545 S. Au6iin /loud 209-599-3492 <br /> L <br /> I CITY STATE I ZIP CODE NEAREST CROSS STRE <br /> T Ripon CA 95366 Ne6t Ril2on i2o <br /> Y CHECK HERE if this ADDRESS should he used for Legal Notification J U N <br /> OPERATOR INFORMATION &ADDRESS (Complete if information different from a"Yj RON MENTAL HEALTH <br /> O NAME OPERATOR CONTACT NAM <br /> P 7i6he2 Nuc6elty, Inc. ae/L2y 7i6he2 / Bn¢d Bloom <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> Al'. O. Box 657 209-599-3412 <br /> T CITY STATE I ZIP CODE <br /> 0 2LRon CA 95366 <br /> R X I CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME OWNER CONTACT NAME <br /> O <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area 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 /> .l. ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P 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 /> Li <br /> UNDERGROUND TANK INFORMATION(List additional tank information on separate sheet If needed.) <br /> T TANK SIZE 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 PL£AS£ NOTE: 7/1626 114S NEVER BEEN ANq UND£i2 ROUND <br /> 1 7,4/WS 47 7111S LOCA) ON. <br /> N <br /> F <br /> O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE.AND CORRECT. <br /> NAME <br /> )TJr— e2iz F.i6he2 TITLE plze,5idenjDATE 5_ <br /> OFFIC . S .ONLY <br /> SWEEPS# I GOMP# TOC CODE I DIST CODE#ACTIVE OUT I#EXEMPTUGT #CIOSEDUGT SWEFFSPRGM/SUBCOD I DATE <br /> EH 23 044(12/88) <br />