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SU0001103
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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2600 - Land Use Program
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MS-92-81
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SU0001103
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Entry Properties
Last modified
5/7/2020 11:28:22 AM
Creation date
9/8/2019 12:42:39 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2600 - Land Use Program
RECORD_ID
SU0001103
PE
2622
FACILITY_NAME
MS-92-81
STREET_NUMBER
7099
Direction
E
STREET_NAME
PELTIER
STREET_TYPE
RD
City
ACAMPO
ENTERED_DATE
10/10/2001 12:00:00 AM
SITE_LOCATION
7099 E PELTIER RD
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\P\PELTIER\7099\MS-92-81\SU0001103\APPL.PDF \MIGRATIONS\P\PELTIER\7099\MS-92-81\SU0001103\CDD OK.PDF \MIGRATIONS\P\PELTIER\7099\MS-92-81\SU0001103\EH COND.PDF \MIGRATIONS\P\PELTIER\7099\MS-92-81\SU0001103\MISC.PDF
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EHD - Public
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;AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> Now .... <br /> UNDERGROUND STORAGE TANK PROGRAM - FARM TANK INFORMATION FORM <br /> ;ACILITY/SITE INFORMATION (Complete this Form for each facility/site) <br /> ARM or BUSINESS NAME ONTACT NAME <br /> I DO SS (S eet address of TANK Locati ) HONE # WITH AREA CODE <br /> L <br /> I <br /> IT TATE 1P CODE EA ST CRO STREET <br /> /11 JE2 2(9 1 <br /> HECK HE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION 8 ADDRESS (Complete if Information Different from Above) <br /> AME <br /> OPERATOR CONTACT NAME <br /> AILING or STREET ADDRESS OPERATOR PHONE # WITH AREA CODE <br /> ITY TATE IP CODE <br /> HECK HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION 3 ADDRESS (Complete if Different from Above) <br /> EATMYE OWNER CONTACT NAME <br /> NG or STREET INFORMATION WNER PHONE # WITH AREA CODE <br /> TATE �ZIP CODE <br /> HECK HERE if this ADDRESS should be used for Legal Notification <br /> Check Appropriate Box <br /> TIVE FARM TANK SITE (One or more underground TANKS > 1,100 gal. capacity) <br /> AXERMANENTLY <br /> EMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gal. capacity) <br /> 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 ESTIMATED 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 /> DDD <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> AME IT E <br /> Al <br /> ATE <br /> �iC <br /> OFFICE UA ONLY <br /> WEEPS OMP # LOC CODE DIST CODE # ACTIVE UGT # EXPEMT UGT # CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 10/89 <br />
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