Laserfiche WebLink
SAN JOAQUIN LOCAL' <br /> HEALTH DISTRICT � <br /> A <br /> �MDFRGRL: <br /> CRAAF TANYPROGRAM - FARM_.IANLINFORMAT _ <br /> FACILITYISITE INFORMATION (complete thiA Form for each FARM TANK locat(on) - <br /> I <br /> FARM or BUSINESS HAVE CONTACT NAME <br /> F <br /> C ADDRESS {Street address of TANK location) PHONE 1 vrTH ARCA Cont i <br /> I <br /> L I <br /> 1 <br /> r CITY STATE i1P CODE NEAREST CROSS STREET <br /> r - <br /> CHEC+f tlEif if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION B ADDRESS (Complete If Information Differint.from Above) <br /> NAME OPERATOR CONTACT NAME <br /> O <br /> P <br /> E MAILING or STREET ADDRESS # OPERATOR PHONE I WI N ARIA CaDC <br /> R <br /> A <br /> T <br /> 0 CITY STATE TIP CODE <br /> R i <br /> p <br /> CRECI PERE I this ADDRESS should be useC for Legal Notification <br /> PROPERTY OWNER INFORMATION I ADDRESS (Coiplete if Diffmrent from Above) <br /> i <br /> NAME OWNER CONTACT NAME <br /> O MAILING or STREET ADDRESS ONHER PHONE 1 MITH MICA coon } <br /> E <br /> R CITY STATE IIP CODE <br /> i <br /> CNECI AERE If this ADDRESS should be used,for Legal Notification <br /> Chtct R1Jropia14 flex <br /> T. ACTIVE FARM TANK SITE (One or more underground TANKS ) 11100 gal. capacity) <br /> Y <br /> P, EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or ( 1100 gal. capacity) <br /> Es <br /> PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place? <br /> (JNDERGROUNO TANK INFORMATION (List Additional tank information on separate sheet if needed) <br /> T TANK SIIE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE i DATE OF REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY AF CURRENILY EMPTY IF PERMANENTLY CLOSED - CLOSURE IN PLACE <br /> N _ <br /> K <br /> r <br /> H <br /> 0 <br /> r <br /> I <br /> THIS FORM HAS BEEN COMPLETED TINDER PENALTY OF PERJURY, AND TO THE BEST OF NY KNOWLEDGE# IS TRUE AND CORRECT <br /> NAME TITLE DATE <br /> __71I <br /> :I <br /> OfF18E dif aril` <br /> SWEEPS 1 COMP 1 LOC CODE DIST COOS 1 ACTIVE UGT '1 EXEMPT UGT 1 CLOSED UGT SWEEPS PRGM/SUB CODE I DATE <br /> EH 23 044 (12198) x <br />