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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 />