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SAN 1AGUIN LOCAL HEALTH DI' 2ICT <br /> UNDERfM OD STORAGE TANK PROGRAM - FARM TANK INFORNAIITA FORM <br /> FACILITY/BITE INFORMATION (Complete this Fon for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F �) f e cL 6roS. Pe-�e Dr t'P CL, <br /> .� A <br /> C ADDRESS (Street address of TANK location) PHONE / WITH A•KA coo■ <br /> E aliooS . C ,L �¢ �P� �o9� S35 , 5- 9>3 <br /> T CITY }—� Q C TATE2DE INEAREST OSS STREET <br /> Y <br /> CMECE #ERE if this ADDRESS should he used for Legal Notification NOV <br /> OPERATOR INFORMATION i ADDRESS (Complete if Information Different from Above) ENilwig nt,.IM _ <br /> F <br /> MANE OPERATOR CONTACT NAME PERMIT/SERVi�-ES <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 WITH AHK^ COOK <br /> R <br /> A <br /> T <br /> 0 CITY STATE 21P CODE <br /> R <br /> CNECE MERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION i ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> n <br /> S O S e G- t E <br /> 0 MAILING or STREET MDRESS OWNER PHONE D WITH AREA COOK <br /> R CITY � S TE ZI CODE� ec_ 63Z <br /> CRICK HERE if Ais ADDRESS should he used for Legal Notification <br /> Cheek Appropriate Box <br /> Y ACTIVE FARM TANK SITE (One or more underground TANKS ) 1,100 gal. capacity) <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site • to or ( 1,100 gal. capacity) <br /> E <br /> 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 /> N (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> K c- er g n ks o I I 719? <br /> 100 I ( d 9to Cv <dmin t / <br /> N <br /> F <br /> 0 a k f�jL12j added Clea m da.* - <br /> THIS FORM HAS KEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAMETITLE OATS <br /> er <br /> OFFICE MSE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE11 ACTIVE UGT 1 EXEMPT UGT 1 CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 (12/88) <br />