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SA W OAQUIN LOCAL HEALTH D TRICT UNDtWUND STORAGE TANK PROGRAM - FARN TANK NF ON FORM FACILITY/SITE INFORMATION (Complete this Form for each FARM TANK location) FARM or BUSINESS NAME CONTACT NAME F A C ADDRESS (Street address of TANK location) PHONE i WITH AREA CODE I L ' ,7 3 T CITY STATE ZIP CODE NEAREST CROSS STREET z,"1)1 1"- CHECK HERE if this ADDRESS should be used for Legal Notification OPERATOR INFORMATION A ADDRESS (Complete if Information Different from Above) NAME OPERATOR CONTACT NAME 0 P E MAILING or STREET ADDRESS OPERATOR PHONE t WITH AREA CODE A T 0 CITY STATE ZIP CODE R CHECK REAE if this ADDRESS should be used for legal Notification PROPERTY OWNER INFORMATION & ADDRESS (Complete if Different from Above) NAME OWNER CONTACT NAME 0 MAILING or STREET ADDRESS OWNER PHONE a WITH AREA CDD. W " F X0`9) 66'a8 y E R CITY STATE ZIP CODE 7 D CHECK HERE if this ADDRESS should be used for Legal Notification Check Appropriate Box T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gal. capacity) Y P EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or ( 1,100 gal. capacity) E X PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) UNDERGROUND TANK INFORMATION (List Additional tank information on separate sheet if needed) T TANK SIZE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL OR A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE N .� _— K SSJ Ct,w e.4 a e s X"aij T N 2e.x6iL ocat- l 7 Aoe)3 I N F 0 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT NAME TITLE DATE U-I a, OFFICE,fif ONLY SWEEPS t COMP a LOC CODE DIST CODE i ACTIVE UGT 1 EXEMPT U6T 1 CLOSED U6T SWEEPS PR6M/SUB CODE DATE I- EH 23 044 (12/80)