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SAN .'^AQUIN LOCAL HEALTH DIS'RICT <br /> UNDERGRber STORAGE TANK PROGRAM - FARM TANK INFORMAT,,eFORM <br /> FACILITY/BITE INFORMATION (Complete thle Fon for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME h/ <br /> A b h kQ o'-- 1U � Pt e 0— <br /> C ADDRESS (Street address of TANK location) PHONE 1 WITH AREA CODE <br /> 1 J <br /> /CS �1 F /mit poi 31 - �1 .S� .Z <br /> T CITY- � ATE IJP CODE NEAREST CROSS TREET <br /> Y fcftr cl tS JCSLn en (Lef- a 2 6 <br /> CRICK NINE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION 1 ADDRESS (Complete if Information Different (roe Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 WITH AREA CODE <br /> R <br /> A <br /> T <br /> EE� STATEIIP CODE <br /> his ADDRESS should be used for Legal Notification c PROPERTY OWNER OWNER INFORMATION 1 ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITH AREA CODE <br /> W <br /> N <br /> E Iswlll <br /> k CITY STALE IIP CODE JAN 2.:9 <br /> CNECL HERE if this ADDRESS should be used for Legal Notification - <br /> CAecJ Appropriate box " <br /> 1 ACTIVE 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 ( 1,100 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 /> I TANK SIZE CHEMICALS ST ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY 0 REVIOUSLI"T IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N _ <br /> K () I-It61vAPV' } jlS ef51pv2J- -1-Al,0-- <br /> I r�' <br /> N CibV�P t-Q I n �"1 0 ( -��- <br /> F <br /> 0 <br /> THIS FORM HA BEEN COMPLETED (NIMER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME ` TITLE DATE <br /> 222 <br /> OFFI& USE ONLY <br /> SWEEPS t COMP 1 LOC CODE DIST CODE R ACTIVE UGT t EXEMPT UGT t CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EN 23 044 (12/88) <br />