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SAN ---.,jADU I N LOCAL HEALTH ll I b--R ICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FARM TANK INFORMATION FORM <br /> FACILITY/BITE INFORMATION (Complete thio Fore for each FARM TANK location) EXEMPT HOME HEATING OIL TANK <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F LEROY METTLER <br /> A <br /> C ADDRESS (Street address of TANK location) PHONE 1 WITH ARIA COPY <br /> L 14090 N. Alpine Road <br /> I <br /> T CITY Lodi , STATE TIP CODE NEAREST CROSS STREET <br /> Y ICA 95240 Harney Lane <br /> CMECI MERE it this ADDRESS should be used lot Legal Notification <br /> OPERATOR INFORMATION i ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 WITH AM"A COY" <br /> R <br /> A <br /> T <br /> 0 CITY SIATE IIP CODE <br /> R <br /> CMECI MERE it this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION A ADDRESS (Complete it Different Irom Above) <br /> MANE OWNER CONTACT NAME <br /> LEROY METTLER <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITH AA"A COY" <br /> W <br /> N 13939 N. Alpine Road (209) 369-8524 <br /> F <br /> R CITY STATE IIP CODE <br /> Lodi , CA 95240 <br /> X CMECI MEfE if this ADDRESS should be used for Legal Notification <br /> CAact Approprlata lox <br /> 1 ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gal. capacity) <br /> Y <br /> P X EXEMPT FARM TANK SITE-Heating Oi 1 (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 SIN 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 550 Diesel May 2 , 1996 closed in ace - May 30, 199 <br /> I <br /> N <br /> F <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY Of PERJURY, AND TO THE BEST Of MY KNOWLEDGE, 19 TRUE AND CORRECT <br /> N f TITLE J�W <br /> !� Owner May 3— ��" ,,z <br /> 0, 1996 <br /> Offlef ufE OMiP <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODEfl ACTIVE UGT 1 EXEMPT UGT 1 CLOSED UGI SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 (12100) <br />