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a <br /> SAN JC`lUIN LOCAL HEALTH DIST CT <br /> UNDERGROUND STORAGE TANK PROGRAM - FARM TANK INFOR i RM <br /> FACILITY/BITE INFORMATION (complete this Fon for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F FAMs , Ld <br /> M ( c( � L � , MACk4,00 <br /> APHONE 1 �r*w "&A cone <br /> C ADDRESS (Street address of TANK location) <br /> Y CITY /���� STATE IIP CODE �3 L NEAREST CROSSSTREw <br /> CNECE NERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION i ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E <br /> MAILING or STREET ADDRESS OPERATOR PHONE I NrTM An" cone <br /> A 11 /�. j�C �S S <br /> k CITY Ll il C STATE IIP�CS➢E <br /> CHFCE NERE 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 YrTM •ece cone <br /> W <br /> N <br /> E <br /> R CITY STATE IIP CODE <br /> CHECE NEAE if this ADDRESS should be used for Legal Notification <br /> check Apropriatf 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 • to or ( 1,100 gal. capacity) <br /> 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 /> I rUeDO C-SG-Z <br /> F <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 /> OFFICE USE ONLY <br /> SWEEPS I COMP 1 LOC CODE DIST CODE A ACTIVE UGIII EXEMPT UGIII CLOSED UGT SWEEPS PRGM/SUB CODE I DATE <br /> IN 23 044 (12/88) <br />