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V <br /> SAN JOAIXIIN COUNTY PUBLIC HEALTH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FARM TANK INFORMATION FORM <br /> FACILITY/SITE INFORMATION (Complete this Form for each facility/site) <br /> ARM or BUSINESS NAME CONTACT NAME <br /> OS isle <br /> DRESS (Street adbress of TANK location) PHONE # WITH AREA CODE <br /> 1 .G�� S /�✓H7�� <br /> ITY T IP CODE EAREST CROSS STREET <br /> ( <br /> NECK HEAE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION 8 ADDRESS (Complete if Information Different from Above) <br /> AME PERATOR CONTACT NAME <br /> (LING or STREET ADDRESS 3PERATOR PHONE # WITH AREA CODE <br /> ITY TATE IP CODE <br /> HECK HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION 8 ADDRESS (Complete if Different from Above) <br /> AME NER CONTACT NAME <br /> (LING or STREET INFORMATION WHEN PHONE # WITH AREA CODE <br /> ITY TATE IP CODE <br /> HECK HERE if this ADDRESS should be used for Legal Notification <br /> Check Appropriate Box <br /> CTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gal. capacity) <br /> PT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gal, capacity) <br /> ERMANENTLY 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 /> TANK SIZE CHEMICALS STORED STIMATED DATE LAST USED MEHTOD OF CLOSURE DATE OF REMOVAL OR <br /> (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> L�- c f�r i �-Y G✓ �' i Yr i;r <br /> THIS FOR HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> AME "2 ITIE <br /> OFFICV USE ONLY <br /> WEEPS IOMP # LOC CODE DIST CODE # ACTIVE UGT # EXPEMT UGT I # CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 10/89 <br />