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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> H R y„AFF TANK PROGRAM - FARM TANK [NFORMATI _ <br /> FACILITY/SITE INFORMATION (Complete this Fon for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME I u <br /> AWITH ARCA COO[ <br /> C ADDRESS (Street address of TANK location) `.Q PHONE 1 <br /> L J A•L[ <br /> T CITY STATE ZIP CODE NEAREST CROSS STREET <br /> Y c� �a36 d ,�r <br /> CHECx HERE if this ADDRESS should be Used for Legal Notification <br /> OPERATOR INFORMATION A ADDRESS (Complete if Information different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 WITH ARCA Coo¢ <br /> R <br /> A <br /> T <br /> 0 CITY STATE ilP CODE <br /> R <br /> CHEC[ HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION 1 ADDRESS (Complete if Different from Above) <br /> F <br /> OWNER CONTACT *ME <br /> STREET ADDRESS OWNER PHONE t WITH ARCA COOK <br /> E <br /> R CITY STATE 21P CODE <br /> CHECK HERE if this ADDRESS should be Used for Legal Notification <br /> Check Appropriate Dox <br /> I 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 if needed) <br /> T TANK S12E 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 <br /> 1 <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 TITLE DATE <br /> OFFICE HSE ONLY <br /> SWEEPS 1 COMP t LOC COOE DIST CODE11 ACTIVE UGT 1 EXEMPT UGT 1 CLOSED UST SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 (12/88) <br />