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�. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE.,, <br /> UNDERGROUND STORAGE TANK PROGRAM - FARM TANK INFORMATION FORM <br /> FACILITY/SITE INFORMATION (Complete this Form for each facility/site) <br /> VRE, NAME ONTACT NAME <br /> 4' BrolWer,s J6e- G0)P)Ar�dddress of TANK location) HONE # WITH AREA CODE <br /> ' S- drru.NeZ9TATE IP CODE EAREST CROSS STREET <br /> k zos- <br /> this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION & ADDRESS (Complete if Information Different from Above) <br /> AME OPERATOR CONTACT NAME <br /> (LING or STREET ADDRESS OPERATOR 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 & ADDRESS (Complete if Different from Above) <br /> AME OWNER CONTACT NAME <br /> (LING or STREET INFORMATION OWNER 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 /> EXEMPT 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 ZSTIMATED DATE LAST USED MEHTOD OF CLOSURE DATE OF REMOVAL OR <br /> (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN <br /> PLACE <br /> S� 4r <br /> THIS FORM H BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> AMEVIC Ck '& I E ATE <br /> p or^ J <br /> OFFI USE ONLY <br /> WEEPS # OMP # LOC CODE I DIST CODE # ACTIVE LICIT # EXPEMT UGT # CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> Z 'afr 16; 32 r .2 3.Z Z 6 p <br /> EN 23 044 10/89 <br />