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SAN J�SUIN LOCAL HEALTH AISTOCT <br /> (1NDERGROUNO 510RAGE TANK �QSR�11 - FARM TANK INFORMATf4t{ FORM <br /> FACILITY/91TE INFORMATION (Complete thle Fora for each FARM TANK location) <br /> FARM or DUSINESS NAME CONTACT NAME <br /> F O� . r» <br /> A <br /> C ADDRESS (Street address of TANK, location) PHONE I WITH ANIA COD& <br /> I <br /> L <br /> ( I 0� <br /> T CITY STATE LIP CODE NEAREST CROSS STREET <br /> Y <br /> MY RIK if this ADDRESS should be used for legal Notification <br /> OPERATOR INFORMATION i ADDRESS (Complete if Inforaation Different Fra Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 4, <br /> E MAILING or STREET ADDRESS OPERATOR PHONE I WITH ANCA CODE <br /> R <br /> A <br /> T <br /> O CITY SIAIE IIP CODE <br /> k <br /> CNEC," 1111E if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION i ADDRESS (Complete If Different frog Above) <br /> NAME V OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE I WITH ANCA CODE <br /> W <br /> N - <br /> k CITY STATE 11P CODE <br /> 0 /) <br /> CHEC1 HE1E if this ADDRESS should be used for Legal Notificition <br /> Checl Atproprietm lox <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 a to or ( 1,100 gal. capacity) <br /> C - <br /> ,� 'PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) <br /> UNDERGROUND TANK INFORMATION (List Additiunal tank information on separate sheet if needed) <br /> T TANK SIIE 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 /> 1 _ �J(� nli Is<l � �,r• "� <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 /> Oida USf OILY <br /> SWEEPS ! COMP 1 LOC CODE DIST COD[ 1 ACTIVE UGI I [TEMPT UGI I CLOSED UGT SWEEPS PRGM/SUO CODE DATE <br /> 111 23 044 (12/80) <br />