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Underground Storage- .,nnk Program - Farm Tank Inf nation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F <br /> FARM or BUSINESS NAME CONTACT NAME <br /> A SEIFERT DAIRY FARMS JOY SEIFERT <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> 1 8505 E. COLLIER RD (209 ) 334-4314 <br /> L <br /> I CITY STATE I ZIPCODE I NEAREST CROSS STREET <br /> T ACAMPO CA 95220 BRUELLA RD <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete if information different from above.) <br /> 0 NAME OPERATOR CONTACT NAME <br /> P SAME <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> R _ <br /> A <br /> .T CITY STATE I ZIP CODE <br /> O <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 SAME <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 EXEMPT FARM TANK SITE ( g g capacity) <br /> P ALL underground TANKS at site = to or < 1,L04 gallon ca cit <br /> E 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 DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY - IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K 6,000 DIESEL TANKS REMOVED June <br /> 1 9,000 GASOLINE June 28, 198 <br /> N with sand. <br /> F <br /> O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT. <br /> NAME e TITLE DATE �j f <br /> OFFICELY <br /> SWEEPSN OOMP# LOC CODE I DIST CODE#ACTIVE UGT I#LXEMPTUGT #CIOSEDUGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044(12/88) <br />