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SAN JC IUIN LOCAL HEALTtt DIST C'f <br /> UNDERGROUND JORA6E TANK PROGRAM FARM TANK INFORMATION TSRH <br /> FACILITY/SITE INFORMATION (Complete this Fore for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME \`y <br /> F Ferguson Farms Inc. <br /> Mr. Robert K. Fergu <br /> C ADDRESS (Street address of TANK location) PHONE 1 WIT" at. `O•& <br /> L 14333 W. Clifton Court Rd. 209/465-9828 <br /> 1 CITY STATE IIP CODE NEAREST CROSS STREET <br /> Y Stockton CA 95206 Tracy Blvd. <br /> CNECI Ifif if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION i ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> f NAILING or STREET ADDRESS OPERATOR PHONE 1 w"" n•c• coo& <br /> R <br /> A <br /> T <br /> O CITY SPATE IIP CODE <br /> k <br /> CNECI YEAE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION N ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> Mr. Robert E. Ferguson <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 "IT" w•c• coo& <br /> IN <br /> 7436 Meadow Ave. 209/564-9828 <br /> CITY <br /> S1AIE 21P CODE <br /> Stockton CA 95207 <br /> X CAECA Iffif if this ADDRESS should be used for Legal Notification <br /> CAect 11protriate lag <br /> 1 ACTIVE FARM TANK SITE (One or more underground TANKS ) 1,100 gal. capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site to or ( 1,100 gal. capacity) <br /> E <br /> X PERMAiiEKTLY -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 ESTIMAIED.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 /> H <br /> K 300 Gasoline (Unlead) 11/84 Removal 11/84 <br /> I — — <br /> N <br /> f <br /> O <br /> THIS FORM HAS BEEN COMPLE D UNDER PENALTY Of PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME 03--,1A -A TITLE DATE <br /> Mr. Rober F r son V P Ferguson Farms 15 May 89 <br /> OFFICE usf oily <br /> SWEEPS I COMP 1 LOC CODE DIST CODE 1 ACTIVE UGT 1 EXEMPT UGT 1 CLOSED UGI SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 (12/88) <br />