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SAN -'iAQUIN LOCAL HEALTH DI- — ICT <br /> UNDER6Rtn fORA6E TANK PROGRAM - FARM TANK INFORMATTLR-rdRM <br /> FACILITY/BITE INFORMATION (Complete this Fore for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME JUN 29 1989 <br /> f � <br /> C ADDRE (Street add ss of TANK location) PHONE 1 WITH •Nce cone pt2lflT/$ER1/ICL„• T,1 <br /> I 1 <br /> L O <br /> I <br /> T CITY S ATE LIP CODE NEAREST CROSS STREET <br /> Y <br /> CRECE NINE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION I ADDRESS (Complete if Information Different from Above) <br /> uA” OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 WITH AREA coot <br /> R <br /> A <br /> T <br /> 0 CITY STATE 11P CODE <br /> R <br /> CNECE HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION i ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> D MAILING or STREET ADDRESS OWNER PHONE 1 WITH RHEA COOK <br /> W <br /> N <br /> E <br /> R CITY STATE 111 CODE <br /> CNECE NEAE if this ADDRESS should he used for legal Notification <br /> CAecY Appopriete box <br /> T <br /> Y ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gal. capacity) <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 /> T TANK SIZE CHEMICALS STORED ESTIMATED DATE LAST 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 —ea <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, 1S TRUE AND CORRECT <br /> NAME ( TITLE DATE <br /> 7/19 <br /> OFFICE USE ONLY <br /> SWEEPS I COMP t LOC CODE DIST CODE11 ACTIVE UGT 1 EXEMPT UGT t CLOSED UGT SWEEPS PRGM/SUB CODE GATE <br /> EH 23 044 (12/88) <br />