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Underground Storage Tank Program - Farm Tank Information Form <br /> FACIUTY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F <br /> A ABF Farm Services, Inc. William W. Salmon <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> 1 12576 W. Clifton Court Road (209) 462-0208 <br /> L' 7-CA <br /> TATE ZIPCODE NEAREST CROSS STREET <br /> I CITY <br /> T Stockton 95206 Tracy Blvd. <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if inrormation different from above.) <br /> O <br /> NAME OPERATOR CONTACT NAME <br /> P ABF Farm Services Inc. William W. Salmon <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area tale) <br /> R (209) 462-0208 <br /> 7-7rI w Undine Roar] <br /> .I CITY STATEZIP CODE <br /> 0 kto C 206 <br /> R CHECK 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 /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <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 /> EXX 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 Pu ed out tank with <br /> K 2000 Regular Gas 1983 Backhoe-backfilled it Nov. , 1986 <br /> I <br /> N <br /> F <br /> 0 <br /> THIS FORM BEEN tOMPL= <br /> UND P OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME �— .TITLE _ DATE = <br /> OFFICE USE ONLY <br /> SWEEPS# COMP# IOC CODE DIST CODE#ACTIVE UGT #EXEMPTUGT #CLOSL•DUGf swEEPSPROm=BCODB DATE <br /> Fl123 044(12/88) <br />