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SAN `7AQUIN LOCAL HEALTH DISTRICT <br /> QNDERGR _ d STONE M PROGRAM - FARM TANK INFORMA FORM <br /> FACILITY/SITE INFORMATION (Complete this Fon for each FARM TANK location) <br /> FARM or BUS ESS NAME CONTACT, ME <br /> A Cc 2 / Y 2 <br /> C ADDRESS (Street address of TANK location) PHONE 1 MR " ""." coos <br /> I <br /> L <br /> 1-21 <br /> T CITY STATE IIP CODE NEAREST CROSS STREET <br /> CHICK fifff if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION i ADDRESS (Coeplete if Infor&ation Different fro& Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 (/ <br /> P <br /> EMAILING or TREET ADDRESS OPERATOR HONE I <br /> R <br /> !A f <br /> 0 CITY <br /> R c- STATE TIP CODE <br /> -" / — <br /> CNECC WERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION 1 ADDRESS (Co&plete if Different fro* Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE t <br /> N <br /> N <br /> E <br /> R CITY STATE 2IP CODE <br /> CNECC MERE if this ADDRESS should be used for Legal Notification <br /> Chfc) h1propriate box <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gal. capacity) <br /> Y <br /> E EXEMPT FARM TANK SITE (ALL underground TANKS at site to or ( 1,100 gal. Capacity) <br /> PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site revved 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 z <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, IS TRUE AND CORRECT <br /> NAME <br /> TITLE DATE <br /> Off ICE HE ONLY <br /> SWEEPS 1COMP 1 LOC CODE DIST CODE 1 ACTIVE UGI 1 EXEMPT UGT 1 CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 (12/88) <br />