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SAN JOAQUIN LOCAL HEALTH DISTmICT <br /> UHDERGRDU,, gIORAGE TANK PROGRAN - FARM TANK INFORMATI Koff <br /> FACILITY/BITE INFORMATION (Coeplete this Fore for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> A <br /> �1/ S -Y/VC . --.T/ / l /�.lAX-lig <br /> C ADDRESS (Street address of TANK location) PHONE 1 WITH AREA COOK <br /> / . 6o E, NZ , X09 - �Gq- 7_S 77 <br /> T CITY STATE ZIP CODE NEAREST CROSS STREET <br /> CNECX YEXE if this ADDRESS should be used for Legal Notification IKI'51zo'too WI% 64 <br /> OPERATOR INFORMATION 1 ADDRESS (Coeplete if Information Different fro& Above) J UIV <br /> NAME % OPERATOR CONTACT NAME ��yyJJ yy��{{�� <br /> P <br /> 9�//' SPC ITIENTAL <br /> /SE&ICES HEALTH <br /> E MAILING or STREET ADDRESS OPERATOR PHONE I WITH AREA CODE <br /> 0 ChCHICK <br /> STATE 11P CODE <br /> R (f A 9 /�. <br /> EA[ if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION L ADDRESS (Complete if Different fro@ Above) <br /> NAME OWNER CONTACT NAME <br /> Y/4/V/q k/� �} c'N ��?� S //1 N/1 <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITH AREA coat <br /> E ``/R/ / / /2/2/9c / 1712 , a0� 7-S <br /> R CITY / STATE ZIP CODE <br /> S �0 ��o�/ �q /� <br /> CNECX NEXT if this ADDRESS should be used for Legal Notification <br /> CAect 411ropriatf box <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 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 00 V/J / E/'Dn 0 <br /> N <br /> p CJ L/ D L^ �7 g'B" <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY Of PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> MAM / TITLE <br /> �� DATE <br /> F ICE USf ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE 1 ACTIVE UGT 1 E)EMPTUGT 1 CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EN 23 044 (12188) <br />