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Underground Stc. ge Tank Program - Farm Tan..,.rnformation Form <br /> FACILITY/SITE INFORMXFION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> A Blossom Farms Inc. Randy Ra kovich <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> 1 10315 N. Highway 88 209-952-3129 <br /> L <br /> 1 <br /> CITY S"FATE 'LIP CODE NEAREST CROSS STREET <br /> T Stockton Ck 95212 Eight Mile Road <br /> Y I CHECK HERE if this ADDRESS should he used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete if information different from above.) <br /> O NAME OPERATOR CONTACT NAME <br /> P Blossom Farms, Inc. Randy Rajkovich <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> R 15400 E. Highway 26 209-952-3129 <br /> A <br /> - — T CITY -- -- - STATE I ZIP CODE- <br /> 0 Linden CA 95236 <br /> RI I CHECK HERE is this ADDRESS should be used for Legal Notification. X - <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME OWNER CONTACT NAME <br /> 0 SAME <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E SAME <br /> R CITY STATE, ZIP CODE <br /> �717CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL undcrground TANKS at site = to or < 1,100 gallon capacity) <br /> E X PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) <br /> UNDERGROUND TANK INFORMA'T'ION (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 500 Gasoline 1984 Removed 3/89 <br /> 1 4000 Diesel 1984 Removed 3/89 <br /> ry N 4000 Diesel 1988 Removed 3/89 <br /> F <br /> \ 0 12000 Diesel 1984 Removed 3/89 <br /> THIS FORM}IAS 'O LETED U AL OP PERJURY,AND TO THE REST OF MY KNOW LFDGF,IS TRUE AND CORRECT. <br /> NAME. ,,.� - �� "TITLE President DATE 7/10/89 <br /> Ole I+ICE USE ONL <br /> SWEEPS# CAMP# LOC CODE DIST CODE#ACTIVE.I IGT #EXEMPT'UCi1' #CLOSEDUGT I SWEEPS PRGM/SUB CODE DATE <br /> El 123 044(12/88) <br />