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SAN JO" 'lUlN LOCAL HEALTH DISTF CT <br /> UNDERG92U0Vf`URA6E TANK PRQQhif - FARM TANK INFORj raj( row <br /> ,AGILITY/BITE INFORMATION (Coepi&te this fore for uch FARM TANK location) A y <br /> (ARM or BUSINESS NAME CONTACT NAME �:1 <br /> f 11 <br /> 6F rzSI 6 WATKJPZ -� -�-e— JUL 3 1 <br /> A <br /> C ADDRESS (Street address of TANK location) PHONE 1 err" ,.c. COOK <br /> I <br /> `7725 N, ESCALDN—[3rLLv7A, a07 987- 3S �NVIRONMENTALHALTH. <br /> I CITY SIA1E IIP CODE NEAREST CROSS STREET <br /> PERMIT/SrRVIC S. <br /> Y L 1A1,0 14;-h/ 041 9S 2 36 H I <br /> CNECI NE11 it this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION L ADDRESS (Coapl&te if Inforsation Different frog Above) <br /> NAME Z-- OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 "" ""cw caac <br /> k <br /> A <br /> T _ <br /> 0 CITY SIAIE IIP CODE <br /> R <br /> CHICl MIA[ if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION i ADDRESS (Coaplete if Dlffu&nt fro& Above) <br /> NAME OWNER CONTACT NAME <br /> v LADDRESS <br /> 0 MAILING or STREET A OWNER PHONE 1WNEk CITY STATEIIP COOECREC[ HERE if ld be used for Legal Nolificition <br /> Chief Allrofriate lox <br /> 14001PI <br /> CTIVE FARM TANK SITE (One or bore underground TANKS ) 1,100 gal. capa(ity) <br /> Y <br /> P FARM TANK SITE (ALL underground TANKS it site to or ( 1,100 gal. capacity) <br /> C <br /> J/ PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS al site reaoved or closed in place) <br /> UNDERGROUND TANK INFORMATION (List Additional tank inforaation on separate sheet if needed) <br /> I TANK SIZE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD Of CLOSURE DATE Of REMOVAL OR <br /> A (GALLONS) CURRCNILY OR PREVIOUSLY If CURRENTLY EMPIY <br /> N If PCknAH[N RY CLOSED CLOSURE IN PLACE <br /> K /ooa v / 9frd' -- b 7 Fl9 <br /> I <br /> N <br /> f <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY Of PERJURY, AND 10 THE BEST Of MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME <br /> TITLE DATE <br /> _(4 L <br /> orrrc[ usE oAtr <br /> SWEEPS 1 COMP 1 LOC COO' 'IST CODE 1 ACTIVE UGI 1 111111 UGT t CLOSED UGI SWEEPS PRGM/SUR CODE <IpIE <br /> EII 20 <br /> 044 (12/88) <br />