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SAN TOA@UIN LOCAL HEALTH DISTRICT <br /> r ! UNDERG, _ .D STORAGE TANK PROGRAM - FARM TANK INFORMA', FORM <br /> FACILITY/SITE INFORMATION (Complete this Fore for each FARM TANK location) <br /> FARM ori-BUSINESS NAME `- CONTACT NAME t <br /> F I N09-tyre4 IGfft.�l-` C�LaTT MAiSC4 <br /> A <br /> C ADDRESS (Street address of TANK location) PHONE I NITN ARRA c"9 <br /> Y CITY ;ORa�� STT ZIP rrDDE NEAgEST CROSS ST EET <br /> �t 'v11 SC��(Co WA1 s1uiv� }DASD <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION i ADDRESS (Complete if Information Different from Above) <br /> NAME. TOR CONTACT NAME <br /> OPERATOR D .� KL If37-pw5r P�T,1.Z541P monAptl-SC4 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 NITN AREA coot <br /> A P. O . l�ax loo <br /> B CITY c— T� STATE ZIP CODE <br /> JT C AV 11 I <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION L ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE I NITN ARCA coot <br /> N 13P'.ftPJllti SERVIC[4. <br /> E <br /> R CITY -FA-TT <br /> IP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> Chert Appropriate Box <br /> T ACTIVE FARM TANK SITE (Dne or tore underground TANKS ) 1,100 gal. capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site R 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 /> T TANK SIZE CHEMICALS STORED ESTIMATED DATE-UST 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 `bo Cateso L.t a 6 t2EMoJE� <br /> I <br /> N <br /> F <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 /> OFFICE USE ONLY <br /> SWEEPS 11c( 1 LOC CODE 01ST CODE11 ACTIVE UGT 1 EXEMPT UGT 1 CLOSED UGT SWEEPS PRfiM/SUB CODE DATE <br /> EH 23 044 (12/88) <br />