Laserfiche WebLink
Underground Stor1ge Tank Program - Farm Tank-Information Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F, FARM or BUSINESS NAME CONTACT NAME <br /> A Brandstad Ranch Dan Brandstad <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> 1 11090 E. Baker Rd. , Stockton, CA 952195 209-931-5406 <br /> L <br /> 1 CITY STATE I ZIP CODE I NEAREST CROSS STREET <br /> T Stockton CA 95205 Beecher Road <br /> Y X—T CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete if information different from above.) <br /> 0 NAME OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> R <br /> A <br /> T CITY STATE I ZIP CODE <br /> O <br /> R CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME OWNER CONTACT NAME <br /> O <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E <br /> R CITY STATE ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> ,I. ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (AL1.underground TANKS at site = to or < 1,100 gallon capacity) <br /> E X 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 /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> K 2000 Gasoline Removed 12/14/88 <br /> 1 2000 Diesel fuel Removed 12/15/88 <br /> N <br /> F <br /> O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME - /.� . r .;�,;, < I' TITLE Partner DATE 26 8 <br /> OFFICE USE ONLY <br /> SWEEPS# COMP# LOC CODE DIST CODE#ACHVE UGT I#EXEMPTUGT #CLOSEDUGT I SWEEPSPRGmruBcoDE DATE <br /> EH 23 044(1Z0) <br />