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SAN IAQUIN LOCAL HEALTH DIF "ZICT <br /> (W^CROO ORD STORAGE TANK PR06RAM - FARM TANK INFORMATM. FORM <br /> FACILITY/SITE INFORMATION (Complete thio Fon for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F <br /> '>At'i 7. <br /> C ADDRESS (Street address of TANK location) PHONE 1 WITH ARCA CGDE <br /> C't'p1 %)cc 5 ,Q�6 ��A✓v' �L�- ✓ c `/ 1 ' 3 yL)S� <br /> Y CITY FSTATE IIP CODE NEAREST CROSS STREET <br /> /� <br /> CNECR HERE if this ADDRESS should be used for Legal Notification tti <br /> OPERATOR INFORMATION W ADDRESS (Complete if Information Different from Above) tt <br /> NAME OPERATOR CONTACT NAME <br /> MAR 2 9 1989 <br /> 0 <br /> P <br /> MA[L!N6 or STREET ADDRESS n1ERA?OR PHONE 1 WITH AREA CanC <br /> ENVIRONMENTAL HEALTH <br /> A PERMITISERVICES <br /> T <br /> 0 CITY 111111 <br /> LIP CODE <br /> R <br /> CHECK #ERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION L ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> T11"C David Price <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITH ARCA CODE <br /> N <br /> E <br /> R CITY STATE 111 CODE <br /> S.53 2c' <br /> CHECK HERE if this ADDRESS should he used for Legal Notification <br /> Check RpProPriate Box <br /> I 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 to or ( 1,100 gal. capacity) <br /> E <br /> xx 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 4,000 Diesel 1981 Removed 3/10/89 <br /> 1 6,000 Diesel 1981 Removed 3/10/89 <br /> N <br /> F 8,000 Diesel 1981 Removed 3/10/89 <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 TITLE DATE <br /> I'.. , President 3/27/89 <br /> OFFICE USE ONLY <br /> SWEEPS t COMP 1 LOC CODEJOIST CODE R ACTIVE UGT 1 EXEMPT 06111 CLOSED UGT SWEEPS PREM/SUB CODE I DATE <br /> EH 23 044 (12/88) <br />