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SAN ' AQIIIN LOCAL HEALTH DIST''ICT <br /> UHDER6RL►- STORAGE TANK PROGRAM - FARM TANK INFORMATkuwKORM <br /> FACILITY/BITE INFORMATION (Complete this Fon for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME (209) 462-4581 <br /> F V,C}u Foppiano Martin Thorpe <br /> A <br /> C ADDRESS (Street address of TANK location) PHONE 1 WITH AREA OOOS (209) 478-6741 <br /> 1 8300 Helen Lane (209) 468-4480 <br /> L <br /> I <br /> I CITY Stockton STAIE IIP CODE NEAREST CROSS STREET <br /> Y CA 95212 Foppiano <br /> CNECA HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INF ATION 1 ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> F G <br /> E MAILIN or STREET ADDRESS OPERATOR PHONE I WITH AREA COOK <br /> R <br /> A <br /> T <br /> 0 CITY STATE IIP CODE <br /> R <br /> CHECK NEAE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OUR INFORMATION IT ADDRESS (Complete if Different from Above) <br /> NAME /I OWNER CONTACT NAME <br /> C`t <br /> D MAILING/or STREET ADDRESS OWNER PHONE 1 WITH AREA COOK <br /> U <br /> N y o �4✓e <br /> F <br /> R CITY L Gk w S+ TIP . <br /> CNECA HERE if this ADDRESS should be used for Legal Notification <br /> Check Appropriate loa <br /> 1 ACTIVE FARM TANK SITE (One or sore underground TANKS ) 1,100 gal. capacity) <br /> Y <br /> P X EXEMPT FARM TANK SITE (ALL underground TANKS at site • to or ( 1,100 gal. capacity) <br /> E <br /> PERMANENILY 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 /> I 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 /> H <br /> K 350 Gasoline 4/16/94 Tank Removal 4/16/94 <br /> N <br /> F <br /> 0 <br /> THIS FORM HAS BEE COMPLETED UNDE MALTY Of PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME TITLE Owner DATE 4/16/94 <br /> G <br /> OFFICE USE 0 IY <br /> SWEEPS t COMP t LOC CODE DIST CODE 1 ACIIVE UGIJI EXEMPT UGT I CLOSED UGI SWEEPS PRGM/SUB CODE DATE <br /> EN 23 044 (12/09) <br />