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SAN JOA(�iN LOCAL HEALTH DISTRI..,, <br /> ghS TINFORMATION FORMFACILITY/BITE INFORMATION (Complettit �ref, ech FARM TANK location) <br /> FARM or BUSIHESS NAME <br /> F CONTACT NAME <br /> A /B ICO�IGf� �riG ��O�J C z�tGSl�o <br /> C ADDRESS (Street address of TANK location) <br /> L PHONE t WITH vas COOK <br /> T CITY <br /> Y � STATE ZIP CODE NEAREST CROSS TREET <br /> LE //7�i> <br /> C#fCI #E8E tf this ADORESS should be used for Legal Notification <br /> OPERATOR INFORMATION It ADDRESS (Complete if Information Different Iron Above) <br /> P NAME <br /> OPERATOR CONTACT NAME <br /> E MAILING or STREET ADDRESS <br /> R OPERATOR PHONE 1 WITH ARiA coda <br /> o CITY X09 B�7 3�2/� <br /> R ��� STATE ZIP CODE <br /> Se236 <br /> C#ECI HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION i ADDRESS (Complete if Different from Above) <br /> NAME <br /> OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS <br /> W OWNER PHONE 1 WITH •RSA COOS <br /> N <br /> E <br /> R CITY STATE ZIP CODE <br /> CHECf #ERE if this ADDRESS should be used for Legal Notification <br /> Chea Appropriate Box <br /> i ACTIVE FARM TANK SITE (Doe or more underground TANKS ) 1,100 gal. capacity) <br /> Y <br /> E EXEMPT FARM TANK SITE (ALL underground TANKS at site • to or ( 1,100 gal. capacity) <br /> PERMANENTLY 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 /> 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 /SOD / 8 /�G�ir,rvoe 3 is 8 <br /> N <br /> F <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, 15 TRUE AND CORRECT <br /> NAME <br /> TITLEDATE <br /> OFFICE USE ONLY <br /> SWEEPS t COMP 1 LOC CODE DIST CODE11 ACTIVE UGT t EXEMPT UGT 1 CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 (12/88) <br />