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SAN JOAQUIN LOCAL HEALTH DISTAYCT <br /> UNDERGROUI� ORALE TANK PROGRAM - FARM TANK INFORMATIOI. a.;11 <br /> FACILITY/BITE INFORMATION (Coeplete this Fon for each FARM TANK location) ' <br /> FARM or BUSINESS NAME CONTACT NAME <br /> A ` CD Z2 � J UN <br /> C ADDRESS (Street address of TANK location) PHONE 1 W'T" AREA 0009 <br /> [1` 2 ,i FSSLTH <br /> i CITY TATE ZIP CODE NEAR ST CROSS STREET <br /> Y r N� S�7i !J 04/ <br /> !HECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION i ADDRESS (Cosplete if Inforution Different froe Above) <br /> NAME OPERATOR CONTACT NAME <br /> P <br /> D P a5 v� <br /> E MAILING or STREET ADDRESS OPERATOR PHONE I WgT" AREA CODE <br /> R <br /> A <br /> T <br /> 0 CITY STATE IIP CODE <br /> R <br /> CNECK YfRE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION 1, ADDRESS lCoeplete if Different (roe Above) <br /> NAME OWNER CONTACT NAME <br /> �.I7r/`f' �S CI <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITN AACA CODE <br /> W <br /> N <br /> E <br /> R CITY STATE IIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> Chief AJAropriatf Bor <br /> Y ACTIVE FARM TANK SITE (One or bore underground TANKS > 1,100 gal. capacity) <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site ■ to or ( 11100 gal. capacity) <br /> E <br /> PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site revved or closed in place) <br /> UNDERGROUND TANK INFORMATION (List Additional tank inforaation 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 <br /> I <br /> N <br /> F <br /> 0 <br /> THIS RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME TITIf{% OAT, <br /> � 7 <br /> OFF CE USE oily <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE 1 ACTIVE UGT I EXEMPT UGT I CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 (12/88) <br />