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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGR .� S(ORAfiE TANK PROGRAM - FARM TANK INFORMAT' �45tl_ <br /> FACILITY/BITE INFORMATION (Complete this Fore for each FARM TANK location) v <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F <br /> A <br /> C ADDRESS (Street address of TANK location) PHONE 1 WITH A COOK <br /> 1 <br /> T CITY U NEAREST CROSS STREET <br /> Y Y1� <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION i ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> fl <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 WITH AREA CODE <br /> R D <br /> A <br /> T V �mu(� <br /> 0 CITYSTATE 11P CODE <br /> R JUN <br /> CNECI YEA[ if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION W ADDRESS (Complete If Different from EfftR,5110w&ftet�j <br /> Above) PERMIT/SERVICES <br /> NAME OWNER CONTACT NAME <br /> i u <br /> 0 MAIL40 or STREET ADDRESS OWNER PHONE 1 WITH ARCA Cooc <br /> W <br /> E -7 <br /> R CITY ST TE IIP CODE <br /> ti `?S9er <br /> CRECA MERE if this ADDRESS should be used for Legal Notification <br /> Chect Aprropriatf Box <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS ) 1,100 gal. capacity) b � <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 SITE 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 S OCG - q <br /> \� uJi - / <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 /> orrr usE ellr <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE 1 ACTIVE UGTt EXEMPT UGT t CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 (12/88) <br />