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SAN AQUIN LOCAL HEALTH D RICT TA 05 i5[V <br /> I <br /> ` ILNDER D STORAGE TANK PROGRAM - FARM TANK INFORM <br /> FORM RDDIt ;�oZD ►i�s OL <br /> FACILITY/SITE INFORMATION (Complete this Fore for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F Borelli Farms Mrs. Dan Borelli <br /> A <br /> C ADDRESS (Street address of TANK location) PHONE i WITH AREA COOS <br /> L 5311 N Jack Tone Rd. (209)931-1633 <br /> I <br /> T CITY S11111111 CODE NEAREST CROSS STREET <br /> Y Stockton, ICA 95215 Raker Rd. <br /> CHECK NEAE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION & ADDRESS (Complete if Inforeation Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 Mrs. Dan Borelli Mrs. Dan Borelli <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 WITH AREA CODE <br /> A5471 N. Jack Tone Rd.. (209)931-1633 <br /> T -T <br /> 0 CITY STATE IIP CODE <br /> R Stockton, CA 95215 <br /> X CHECK NEAE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION Ir ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITH AREA COOT <br /> W <br /> N <br /> E <br /> R CITY STATE IIP CODE <br /> CHECK #ERE if this ADDRESS should be used for Legal Notification <br /> CAect Appropriate Box <br /> Y ACTIVE FARM TANK SITE (One or more underground TANKS > 11100 gal. capacity) <br /> P X EXEMPT FARM TANK SITE (ALL underground TANKS at site s to or ( 11100 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 /> N (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> K 250 unleaded gasoline 5/31/98 removal 6/5/98 <br /> I <br /> N <br /> F <br /> 0 <br /> THII FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> N I" <br /> All TITLE ��2Ril/ DATE <br /> OFFICE USE ONLY <br /> SWEEPS t COMP ! LOC CODE BIST CODE11 ACTIVE U6T 1 EXEMPT U6T 1 CLOSED UGT SWEEPS PR6M/SUD CODE DATE <br /> EH 23 044 (12100) <br />