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' SAN J*,,VQUIN LOCAL HEALTH DIS',,JCT <br /> UNDERGROUND STORAGE TANK PROGRAM - FARM TANK INFORMATION FORK <br /> FACILITY/SITE INFORMATION (Complete this Fon �ppjggz for each FARM TANK location) I <br /> FARM or BUSINESS NAME CONTACT NAME <br /> f <br /> APR 2 8 1989 <br /> A <br /> C ADDRESS ( tre address o TANK location) PHONE 1 N'TN ANSA COOK v i'<GN+viENTAI HEALTH <br /> L O ERMIT/ RVICES <br /> 1 <br /> T CIT STATE II C E [NEARESTCROSS STREET <br /> Y <br /> x CHECK SERE it this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION i ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE I N'TN ANCA CODS <br /> R <br /> A <br /> T <br /> 0 CITY STATE " CODE <br /> R <br /> CNECC PERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION b ADDRESS (Complete If Different from Above) <br /> NAME OWNER CONTACT NAME <br /> D MAILING or STREET ADDRESS OWNER PHONE 1 "`'TTN A•eA cool <br /> R CIT STATE IIP CODE <br /> 0 <br /> CNECE #ERE if this ADDRESS should be used for Legal Notification <br /> Check ilproprJatm Bax <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gal. capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site to or ( 1,100 gal. capacity) <br /> E <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 it 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 /> K SD /� a o FAL5 � w <br /> I fly q0 <br /> N <br /> F <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME TITL DATE <br /> OFFICE USE OR y Q <br /> SWEEPS 1 COMP 1 LOC COBE DIST CODE11 ACTIVE UGT 1 EXEMPT UGT 1 CLOSED USTI SWEEPS PRGM/SUB CODE I DATE <br /> 5 <br /> EH 23 044 (12188) <br />