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Underground Stf.,_,ge Tank Program - Farm Tan»nformation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> A Tiehe2 Nu26e1zy, Inc. jcizzy Tihhe2 / B/zad Bloom <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> L <br /> L 24081 S. Au6tin Rd. 209-599-34 <br /> IjijywftVMl,j Wpm <br /> I CITY STATE ZIP CODE NEAREST CROSS STREET <br /> MCLO <br /> T I i� cn CA 95366 Id. Ripon load <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification -I'JVINUNMtN IAL <br /> ALTH <br /> 0I'EItA1'OR INFORMA'T'ION & ADDRESS (Complete If information different from above.) PERMIT/SERV ; <br /> 0 NAME OPERATOR CONTACT NAME <br /> P Tt6he2 NaA6eizy, Inc. aenny Ti6heiz / B2ad Bioom <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> R P. 0. Boz 657 209-599-3472 <br /> A <br /> T CITY SPATE ZIP CODE <br /> 02ipon CA 95366 <br /> R X CIIECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPER'L'Y 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 HPRF if this ADDRESS should he used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> .1. 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 X PERMANENTLY CLOSED FARM TANK SITE (AIL underground TANKS at site removed or closed in place) <br /> I <br /> UNDERGROUND TANK INFORMATION(List additional tank Information on separate sheet If needed.) <br /> T TANKSI7.E CHEMICALSSPORL'D ESTIMATED DATE LAST USED ME"1710DOFCLOSURr DATE OF REMOVAL Olt <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLUED CLOSURE IN PLACE <br /> N Back1tPted Mill' <br /> K U00 ae N/A foam 6 ,e Nov. 1986 <br /> Backliteed with <br /> 1 <br /> 10, 000 D e6ee N/A ioam 60i2 Nov. 7986 <br /> N <br /> F <br /> O <br /> THIS FORM IIAS UEEN COMPLETED UNDER PENALTY OF 1'MURY,AND TO THE RST OF MY KNOWLEDGE IS TRUE AND CORREX-r. <br /> NAME " e22 7.iehe2 TITLE P/zeh.ide.nt DATE05-29-90 <br /> OFFICE USI:ONLY <br /> SWIiEL'S# I (AMP# IOC CODE I DIST CODENACTIVE UGT I#EXEMPT UGf 10 CLOSED uOT I SWEETS PRGM/SUB CODE DAl'li <br /> El 123 044(12/8R) <br />