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SAN TOAQUIN LOCAL HEALTH DT TRICT <br /> UNDER".- JNO STORAGE TANK PR06RAM - FARM TANK INFORM A FORM <br /> FACILITY/SITE INFORMATION (Complete thio Fora for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F <br /> A <br /> C ADDRESS (Street address of TANK location) PHONE 1 WIT. "a. coca <br /> I <br /> L 3 N Ct+L2ok�E <br /> Y CITY L O 1 STATE ZIP COD NEAREST CROSS STREET <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION i ADDRESS (Complete if Information Different frog Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 WITH AHK• COOK <br /> R <br /> A <br /> 0 CITYSTATE ZIP CODE <br /> R / A 5Z <br /> CHECK NEAE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION It ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> D MAILING or STREET ADDRESS OWNER PHONE 1 WITH •mKA COOK <br /> W <br /> N <br /> E <br /> R CITY STATE i1P CODE <br /> CNECK HERE if this ADDRESS should be used for Legal Notification <br /> Chea Appropriatf Box <br /> 1ACTIVE FARM TANK SITE (One or sore underground TANKS ) 1,100 gal. capacity) <br /> Y <br /> P <br /> E EXEMPT FARM TANK SITE (ALL underground TANKS at site to or ( 1,100 gal. capacity) <br /> PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site gemoved-'o) 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 DAT MOVAL OR <br /> A tGALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY If PERMANENTLY CLOSED CL URE <br /> IN L <br /> N <br /> K Sv ���1r1E LLuI: <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 BBE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE11 ACTIVE UGT 1 EXEMPT UGT t CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 (12/88) <br />