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P_ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGT STORAGE TANK PROGRAM - FARM TANK INFORMA' FORM <br /> FACILITY/BITE INFORMATION (Coeplete thie Fore for each FARM TANK location) y <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F Merry & Jiro Sasaki Merry or Jiro Sasaki <br /> A <br /> C ADDRESS (Street address of TANK location) PHONE 1 WITH AaEA CODE <br /> L 3098 E. Jahant Road <br /> 209 333-2188 <br /> 1 <br /> 1 CITY STATE IIP CODE NEAREST CROSS STREET <br /> YAcampo I CA 95220 Hi . 99/Jahant Road <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION i ADDRESS (Coeplete if Inforeation Different froe Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 WITH AREA "COE <br /> R <br /> A <br /> i <br /> 0 CITY STATE TIP CODE <br /> r <br /> k J w iR <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION 4 ADDRESS (Coeplete if Different hoe Above) <br /> NAME OWNER CONTACT NAME'' " <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITH AREA COO' <br /> W <br /> N <br /> E <br /> R CITY STATE IIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CAect Appropriate dor <br /> 1 ACTIVE FARM TANK SITE (One or wre underground TANKS > 1,100 gal. capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site E to or ( 11100 gal. capacity) <br /> E <br /> ` PERMANENILY CLOSED FARM TANK SITE (ALL underground TANKS at site revved or closed in place) <br /> UNDERGROUND TANK INFORMATION (List Additional tank inforeation 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 295 Gal gasoline 1983/84 est. removal 9-4-89 <br /> I 300 Gal gasoline 1983/84 est. removal 9-4-89 <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 Merry Sasaki TITLE owner DATE Sept 4, 1989 <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE11 ACTIVE UGT t EXEMPT UGT 1 CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 (12/88) <br />