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SAN •OAQUIN LOCAL HEALTH DT -'TRICT <br /> UMQER ,WND STORAGE TANK PR06RAP - FARM TANK INFQM;;UN FORM <br /> FACILITY/SITE INFORMATION (Complete thio Fon for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F DARWIN—SU, INC . DARWIN LEWIS <br /> A <br /> C ADDRESS (Street address of TANK location) PHONE 1 WITH AREA Cao■ <br /> 1 23709 E. BRANDT ROAD 209-727-5577 <br /> L <br /> I <br /> T CITYy STATE ZIP CODE NEAREST CROSS STREET <br /> Y �CMUECIMEIE <br /> CA 95240 CLEMENTS ROAD <br /> this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION i ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILIN6 or STREET ADDRESS OPERATOR PHONE 1 WITH AREA CODE <br /> R <br /> A <br /> T <br /> 0 CITY STATE ZIP CODE <br /> R <br /> CHECK NEAE if this ADDRESS should be used for Legal Notification <br /> PROPERTY QUIN:R INFORMATION b ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> � u <br /> 0 MAILIN6 or STREET ADDRESS OWNER PHONE 1 -01#14A-Am A u <br /> N F E B 1 5, "1 <br /> R CITY STATE ZIP CODE �-NVIRONMENTAL HEALTH <br /> ERVICE'S <br /> CRECK MERE 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 gal. capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site a to or ( 1,100 gal. capacity) <br /> E <br /> V 1PERMAPENTLY CLOSED FARM TANK SITE (ALL undernround TANKS at site removed or closed in olace) <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®VA OR <br /> A (6ALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE TA PLACE <br /> N <br /> K 10 , 000 GAS 2-1-89 REMOVED 3-1-89 <br /> 1 10 , 000 DIESEL 2-1-89 REMOVED 3-1-89 <br /> N <br /> F 1 , 500 GAS 2-1-89 REMOVED 3-1-89 <br /> 0 <br /> 1 , 500 GAS 2-1-89 REMOVED 3-1-89 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME j TITLE PRESIDENT DATE 2-10-90 <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP 177 DIST CODE t ACTIVE U6T 1 EXEMPT UGT 1 CLOSED UGT SWEEPS PREM/SUB CODE OATE <br /> EH 23 044 (12/88) <br />