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SAN LOCAL HEALTH DI ` " ICT <br /> UNDERGR(AF 'TORAGE TANK PROGRAM - FARM TANK INFORMATlU�ORM <br /> FACILITY/SITE INFORMATION (Complete this Fon for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F tiaH ,HaK r <br /> A WITH AREA COOK <br /> La xc z - 1 <br /> C ADDRESS (Street address of TANK location) PHONE <br /> I 3 1C z <br /> L -t 3— <br /> Tt✓ ,4' Qwrv`" lav �73Jo ._..y <br /> 1 cc <br /> T CITY STATE ZIP CODE NEAREST CROSS STREET <br /> Y Z-1n � G 9szac •n��., ,r� <br /> CNECI NINE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION i ADDRESS (Complete if Inforution Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 WITH AREA COOK <br /> R <br /> A <br /> T <br /> 0 CITY STATE 11P CODE <br /> R <br /> CNECI NEA[ if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION i ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITH AREA COOK <br /> W D <br /> N <br /> R CITY STATE 1IP CODE <br /> CNECI NINE if this ADDRESS should be used for Legal Notification 2 <br /> "q N49Y <br /> Chief ApArCpriefe Daa p'' <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 • to or ( 1,100 gal. capacity) <br /> E <br /> PERMANEMILY 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 /> Zi;aC K 3-"1 - <br /> u <br /> N <br /> F <br /> O <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 /> ci <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE 1 ACTIVE UGT 1 EXEMPT UGT 1 CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EN 23 044 (12/88) <br />