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tiAN JUAUUIN LOCAL HEALTH DISTRICT <br /> UNDER@ 0 STORAGE TANK PROGRAM - FARM TANK INFORU FORM <br /> FACILITY/RITE INFORMATION (Complets this Form for each FARM TANK location) <br /> FARM or BUSINESS NAME // CONTACT NAME <br /> F JORfltI.l..f,� l—fll� MZ/UG'. C�0m?,9 /u Vrii. Ur1 ;�GE'OE4L6 <br /> A <br /> C ADDRESS (Street address of TANK location) PHONE 1 WITH Y[. COO/ <br /> L �335sb Uz2p lee <br /> 1 <br /> T CITY STATE ZIP CODE NEAREST CROSS STREET <br /> Y / 1?,ge v,h i5 3 74 'E /L v c A2 lZ <br /> CNECI Of if this ADDRESS should be used for Legal Notification <br /> OPERATOR IBFORMATIOR a ADDRESS (Complete if Inforution Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE I WITH A•cA Co•i <br /> R <br /> A 6'"o Z 5; ;' pro <br /> f ' <br /> 0 CITY STATE 11P CODE <br /> R <br /> CHECI REIT if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION It ADDRESS (Complete if Different from Above) <br /> MANE OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITH ..cA CQQ9 <br /> W <br /> N <br /> E <br /> R CITY SZATE IIP CODE <br /> CHICI HERE if this ADDRESS should be used for Legal Notification <br /> CAecl AAAropriate box <br /> Z 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 revved 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 EhPIY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K 550 R� ul� r FweL <br /> I O n Le d ed `(a- <br /> N <br /> F <br /> 0 ^ <br /> L e Ur)ler ., r0 .1 .,4 I I }u 5/ .0 r D /'o ^C r. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY Of PERJURY, AX0 TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME TITLE J DATE <br /> OFFICE Hf OBIT <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE 1 ACTIVE UGJ 1 EXEMPT UGT I CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> Ell 73 044 (12/80) <br />