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SAN JC 7UIN LOCAL HEALTH DIST C"I <br /> UNDERGROUNMORA6E TANK PROGRAM - FARM TANK INFOkMATION TERM <br /> FACILITY/SITE INFORMATION (Complete this Fon for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F Ferguson Farms Inc. Mr. Robert K. Ferguson <br /> A <br /> C ADDRESS (Street address of TANK location) PHONE 1 "lT" eDEA cook a <br /> l —40 <br /> 14333 W. Clifton Court Rd. 209/465-9828 1�Q ✓� <br /> T CITY STATE 11P CODE NEAREST CROSS STREET NN <br /> Y StocktonCA 95206 Tracy Blvd. , V <br /> CNECI ofof if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION L ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 "'T" •"Ek CODE <br /> R <br /> A <br /> T <br /> 0 CITY SLATE 11P CODE <br /> k <br /> 1. CNECI NEAP if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION b 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 """ •DEA CODE <br /> W <br /> N 7436 Meadow Ave. 209/465-9828 <br /> K CITY tocktonJ�TE 1S5tE/ <br /> X CHICK NEIf if this ADDRESS should be used for legal Notificition <br /> Chet Itfrmpriete far <br /> I ACTIVE fARM TANK SITE One or more underground TANKS ) 1,100 gal. capacity) <br /> Y <br /> P EIEMPT FARM TANK SITE (ALL underground TANKS at site to or ( 1,100 gal. capacity) <br /> E <br /> PERMANEHILY CLOSED FARM TANK SITE (ALL underground TAWKS at site removed or closed in place) <br /> UNDERGROUND TANK INFORMATION (List Additional tank information on separate sheet it needed) <br /> T TANK SITE CHEMICALS STORED ESTIMATED.OAIE 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 500 Heating Oil 1984 Removal 11/84 <br /> H <br /> 0 <br /> THIS FORM HAS BEEN CONPLETED NDER PENALTY OF PERJURY, AND TO THE BEST OF NY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME fyE. TITLE DATE <br /> Mr. Rob rt K. Fe;gu4n V.P. Ferguson Farms 15 May 89 <br /> OffFCf Ulf Doty <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE t ACTIVE UGT t EIEMPI UGIJI CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EN 23 044 (12/00) <br />