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SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FARM TANK INFORMATION FORM <br /> FACILITY/SITE INFORMATION (Complete this Form for each facility/site) <br /> ARM or BUSINESS NAME CONTACT NAME <br /> 1 kDDRESS (Street address of TANK location) PHONE # WITH AREA CODE <br /> I 173V S. ITA <br /> ITY CODEEAREST CROSS STREET <br /> oScq 20 <br /> XECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION & ADDRESS (Complete if Information Different from Above) <br /> AME OPERATOR CONTACT NAME <br /> 71 <br /> (LING or STREET ADDRESS OPERATOR PHONE # WITH AREA CODE <br /> ITY TATE IP CODE <br /> HECK HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION & ADDRESS (Complete if Different from Above) <br /> AME OWNER CONTACT NAME <br /> ILING or STREET INFOR ATION OWNER PHONE # WITH AREA CODE <br /> ITY TATE IP CODE <br /> HECK HERE if this ADDRESS should be used for Legal Notification <br /> Check Appropriate Box <br /> CTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gal. capacity) <br /> EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gal. capacity) <br /> ERMANENTLY 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 /> TANK SIZE CHEMICALS STORED ESTIMATED DATE LAST USED MEHTOD OF CLOSURE DATE OF REMOVAL OR <br /> (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED / CLOSURE IN PLACE <br /> I <br /> THIS FORM HAS BEEN COMPO D UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> AME <br /> ITLEATE f 1, " <br /> OFF CE USE ONLY t/Yn <br /> 3`tL U <br /> WEEPS # OMP # LOC CODE DIST CODE # ACTIVE UGT # E%PEMT UGT # CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EX 23 044 10/89 <br />