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Underground Stora , Tank Program - Farm Tank T- Formation Form <br /> FACILITYISITE INFORMATION (Complete this form for each FARM TANK location.) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F <br /> A Ole R. Mettler <br /> Ole R. Mettler <br /> C ADDRESS(Sheet address of TANK location) PHONE# (with area code) <br /> 1 17900 North Cherry Road (209 ) 369-9119 <br /> L <br /> I CITY STATE ZIP CODE NEAREST CROSS STREET <br /> T Lodi Ca. 95240 Highway 12 <br /> Y I X I CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete if information different from above.) <br /> O NAME OPERATOR CONTACT NAME <br /> P Bruce A. Mettler Bruce A. Mettler <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> R <br /> A 17901 North Cherry Road (202) 369-4905 <br /> ,1, CITY STATE ZIP CODE <br /> 0 Lodi Ca. 95240 <br /> R CI IECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME OWNER CONTACT NAME <br /> O <br /> W MAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> N <br /> E <br /> R CITY STATE I ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> ,I, ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> F' X 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 DATEOPREMOVALOR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K 550 Gasoline Removed — <br /> 1550 Diesel <br /> N 250 Gasoline Ppmovprl Wintpr AR—RQ <br /> F <br /> O 550 — <br /> THIS FORM RAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME W. 11 TITLE DATE Q <br /> OFFICE USE ONLY <br /> SWEEPS# I ODMP# LOC CODE I DIST CODE#ACTIVE UGT #EXEMPTUGT #CI.OSF,DUGT SWEEPS PRGM/SIJBCODE DATE <br /> /(/� <br /> " D EH 23 044(12/88) <br />