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SAN J' ' QUIN LOCAL HEALTSan Joaquin County <br /> u61ic Health Services <br /> UNDERBROU01111TORAGE TANK PROGRAM FARM TANK E _ onmental Health Division <br /> FACIIItTBITE INFORMATION (Complete this Fon for each FARM TANK location) C you 2009, Stockton, California 55201 <br /> Tom or BUSINESS NAME CONTACT NAME <br /> C AD KESS (Street ddress of TANK location) PHONE 1 WITH AAtA coot <br /> Y IIY STATE 11P CODE NEARES CROSS STREET <br /> G Zdz) o/Ue. <br /> CMECE I[IE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION It ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> E MAILING or ST ET ADDRESS OPERATOR PHONE 1 YtIN AALA coo <br /> R <br /> " - o. .07 � <br /> IT <br /> 00 CITY G ST TE ZIP CODE K . <br /> ,1 <br /> HECK (EAE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION W ADDRESS (Complete If Different from Above) J U L 0 9 1990 <br /> NAME OWNER CONTACT NaNVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITH ANCA cool <br /> W <br /> N <br /> E <br /> R CITY STATE IIP CODE <br /> t1ECI IEAf if this ADDRESS should be used for Legal Notification <br /> Chief Apfrofriate Boa <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gal. capacity) <br /> Y <br /> P EiENPT FARM TANK SITE (ALL underground TANKS at site • to or ( 11100 gal. capacity) <br /> E <br /> 14 ERNANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) <br /> UNDERGROUND TANK INFORMATION (List Additional lank 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 <br /> I t <br /> N <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 /> 7 I <br /> OFFIVBSE ILY <br /> SWEE S 1 COMP 1 LOC CODE DIST CODE 1 ACTIVE 11TI, EIEMPT UGI �LHED SWEEPS PRGM/SUB CODE DATE <br /> IN 23 044 (12/88) <br />