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SAN JQAOUIN LOCAL HEALTH DIST-PICT <br /> UNDERGRO�-STORAGE TANK PROGRAM - FARM TANK INFORMATIC SRM <br /> FACILITY/SITE INFORMATION (Complete this Fore for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F Robertson & Sons Stanley A. Robertson <br /> A <br /> C ADDRESS (Street address of TANK location) PHONE 1 WITH "CA Coo■ <br /> I <br /> L 27337 S Banta Road 209 835-0542 <br /> 1 <br /> Y CITY Trac TATE ZIP CODE NEAREST CROSS STREET <br /> y� a 95376 Linne Road <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION A ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> P P - <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 WITH AA-A COfRPA1?/SERVhE <br /> R <br /> A <br /> T <br /> 0 CITY STATE 11P CODE <br /> R <br /> CNECE HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION b ADDRESS (CompletR'otere if Different from Above) <br /> NAME <br /> Clifford & Louella Robertson, & OWNER CONTACT NAME <br /> Gerald A. Robertson <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITH AREA coo[ <br /> W <br /> N same as above same as above <br /> E <br /> R CITY STATEZIP CODE <br /> CHECK HERE if this ADDRESS should be used for legal Notification <br /> Chtef 111ropriate sox <br /> TACTIVE 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 ( 11100 gal. capacity) <br /> E <br /> PERMANENTLY 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 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 4000 Diesel 1987 Removed 1987 <br /> 1 1500 Gas June, 1989 Removed June 1989 <br /> N <br /> F 2000 Gas June, 1989 Removed June 1989 <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST Of MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME � TITLE DATE <br /> 0�.-�C.,.Jf.._.— Partner/Owner /.0.- <br /> OiFZCE USE OILY <br /> SWEEPS 1 COMP t ILOC CODE DIST CODE11 ACTIVE UGT 1 EXEMPT UGi 1 CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 (12/88) <br />