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I , <br />SAISOAQUIN LOCAL HEALTH D&RICT <br />UNKRGROUND STORAGE TANK PROGRAM - DO TANK 11(FORNA110A FOR# <br />FACILITY/61TE INFORMATION (Cosplete this Fore for aach FARM TANK location) <br />FARM or BUSINESS NAME <br />CONTACT NAME <br />f Mohammed Malik. <br />Dale Jolley <br />A <br />Dale Jolley <br />C ADDRESS (Street address of TANK location) <br />PRONE 1 " "" ""`" °O°" <br />L 6550 E. Hwy 12 <br />(209)334-1402 <br />T CITY <br />STATE <br />ItP CODE <br />NEAREST CROSS STREET <br />YLodi <br />CA <br />95240 <br />Techlenberg <br />IIP CODE <br />Wafts Iffif it this ADDRESS should be used for legal Notification <br />WHIM INUIRRATTmN L ADDRESS (Cnaalata it Inforcation Differenl Ira Above) <br />NAME <br />NAS <br />OPERATOR CONTACI NAME <br />0 <br />Mohammed Malik <br />Dale Jolley <br />P <br />E NAILING or STREET ADDRESS <br />OPERATOR PHONE ! "i'l$ wwiA COYi <br />R <br />A <br />1222 Cedar Creek Ct. <br />(913)661-9972 <br />T <br />N <br />PERMANENTLY CLOSED FARM TANK SITE <br />(ALL underground TANKS at site <br />R <br />CITY <br />0 CITY11A <br />IIP CODE <br />LATE <br />11P CODE <br />CNEtt Nflf if this ADDRESS should be used for Legal Notification <br />R <br />Modesto <br />95355 <br />X <br />CHH 11HE if this ADDRESS should be used for Legal Notificat(oa <br />oonnroN nuuro IYcnowATlnM i OWN itaAnt.t■ it Dill rant hat Above) <br />ti.Al AufAaDjIfI IAl1 <br />NAS <br />OWNER CONTACT NANE <br />METHOD Of CLOSURE <br />If PERMANENTLY CLOSED <br />Same as above <br />ACTIVE FARM TANK SITE <br />0 <br />MAILING or STREET ADDRESS <br />OWNER PHONE 1 <br />u <br />(ALL underground TANKS at site <br />• to or ( 1,100 gal. cap a ity) <br />N <br />PERMANENTLY CLOSED FARM TANK SITE <br />(ALL underground TANKS at site <br />R <br />CITY <br />STATE <br />IIP CODE <br />0 <br />CNEtt Nflf if this ADDRESS should be used for Legal Notification <br />ti.Al AufAaDjIfI IAl1 <br />iwaros91NWe TINY ITN OeMAT10Y It ist Additional tint inforaAtion on separate sheet it needed) <br />T TANK SIIE <br />A (GALLONS) <br />CHEMICALS STORED <br />CURRENTLY 09 PREVIOUSLY <br />ESIINATED DATE LAST USED <br />If CURRENTLY EMPTY <br />METHOD Of CLOSURE <br />If PERMANENTLY CLOSED <br />I <br />ACTIVE FARM TANK SITE <br />(Dna or sora underground TANKS <br />) 1,100 gni. capacity) <br />V <br />P X <br />EXEMPT FARM TANK SITE <br />(ALL underground TANKS at site <br />• to or ( 1,100 gal. cap a ity) <br />F <br />PERMANENTLY CLOSED FARM TANK SITE <br />(ALL underground TANKS at site <br />resoved or closed in place) <br />iwaros91NWe TINY ITN OeMAT10Y It ist Additional tint inforaAtion on separate sheet it needed) <br />T TANK SIIE <br />A (GALLONS) <br />CHEMICALS STORED <br />CURRENTLY 09 PREVIOUSLY <br />ESIINATED DATE LAST USED <br />If CURRENTLY EMPTY <br />METHOD Of CLOSURE <br />If PERMANENTLY CLOSED <br />DATE Of REMOVAL OR <br />CLOSURE IN PLACE <br />T <br />N <br />K unknown <br />--- <br />gasoline <br />unknown <br />removal <br />1/8/97 <br />1,000 <br />gasoline <br />unknown <br />removal <br />2/13/97 <br />H <br />f <br />0 <br />THIS FORM HAS BEEN COMPLETEI UNDER PENALTY Of PERJURY, AND TO THE BEST Of MY KNOWLEDGE, IS TRUE AND CORRECT <br />NAME n TITLE DATE <br />owrier <br />Mff Ysr ally <br />SWEEPS 1 COMP 1 LOC CODE DIST CODE 1 ACTIVE U6111 ETEMPT N111 CLOSED Ni SWEEPS PREM/SUB CODE OA1E <br />EH 23 044 (12188) <br />