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SAN -`JAOUIN LOCAL HEALTH DIP--QICT <br /> IND RGh"D STORAGE TANK PROGRAM - FARM TANK INFORMATIVK FORM <br /> FACILITY/BITE INFORMATIDN (Complete this Fore for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME _ <br /> F David T. Price, Inc. David Price <br /> A - <br /> C ADDRESS (Street address of TANK location) PHONE I WITH ARRA coo■ tj <br /> L 21635 E. Dodds Rd. MAR 291989. <br /> 1 <br /> T CITY STATE IIP CODE NEAREST CROSS STREET <br /> Y Escalon CA 95320 - <br /> CNECA HERE if this ADDRESS should he used for Legal Notification PERPAIT/SERVICES <br /> OPERATOR INFORMATION L ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE I WITH ARCA CODE <br /> R' <br /> A <br /> T <br /> 0 CITY STATE IIP CODE <br /> R <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION & ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> David T. Price, Inc. David Price <br /> 0 MAILING or STREET ADDRESS OWNER PHONE I WITH ARCA CODE <br /> W <br /> N 21657 E. Dodds Rd. 209-465-3405 <br /> E <br /> R CITY STATE IIP CODE <br /> Escalon CA 95320 <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> Check Appropriate Box <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gal. capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site R 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 /> A (GALLONS) CURRENTLY OR PREVIOUSLY If CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K 1989 Removed 3/25/89 <br /> N c) /2 P L 1988 Removed 3/25/89 <br /> 5G „z jc-n :Zt,L 1988 Removed 3/25/89 <br /> SCS✓ 2e5 -L 1981 Removed 3/25/89 <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 President DATE 3/27/89 <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE t ACTIVE UGT I EXEMPT UGT I CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EN 23 044 (12/88) <br />