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SAN JL—,JUIN LOCAL HEALTH DIST.r,,,JT <br /> UNDERGROUND STORAGE TANK PROGRAM - FARM TANK tHrORMATION FORM <br /> FACILITY/BITE INFORMATION !Complete this Fon for each FARM TANK location) <br /> FARM or BUSINESS NAME C�4K'r-1LI1i�s CONTACT NAME <br /> r C'AK'o C)NEsi � 'i�D Nfv <br /> A <br /> C ADDRESS (Street address of TANK location) PHONE 1 WITH ""KA COOK <br /> �— <br /> T CITY STATE IIP CODE NEAREST CROSS STREET <br /> Y 17�I C if 5�'f )- <br /> Y CHECK N[ff if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION 1 ADDRESS (Complete If In(oreation Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 WITH ""c" CODE <br /> R <br /> A <br /> T <br /> 0 CITY STATE 11P CODE <br /> k <br /> CHICK HIAE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION 6 ADDRESS (Complete if Different (roe Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITH "Kc" CODE <br /> W <br /> N <br /> E <br /> R CITY STATE i1P CODE <br /> CHICK NEAf if this ADDRESS should be used for Legal Notification <br /> Chu) Approtriate tax <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 ( 11100 gal. capacity) <br /> C <br /> K 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 SITE 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 ASO EAS01 ;A/E- 49K4 11160s cN/OG''4-D <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 /l& � /,�t��� w TITLE61� DATE <br /> Offrcr USE ONLY <br /> SWEEPS 1 COMP I LOC CODE DIST CODE 1 ACTIVE UGT 1 EXEMPT UGT 1 CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 (12IBB) <br />