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Underground Stl _ .ge Tank Program - Farm Tari._:_information Form <br /> FACILITY/SITZ:INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> A <br /> C ADDRESS (Street address of TANK location) PHONE N (with arca code) <br /> I <br /> L <br /> 1 CITY STATE I ZIP CODE I NEAREST CROSS STREET <br /> T <br /> Y CLIF.CK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION &ADDRESS (Complete If Information different from above.) <br /> O NAME OPERATOR CONTACT NAME <br /> D <br /> E MAILING or STREET ADDRESS OPERATOR PHONE N (with area code) <br /> R <br /> A <br /> T CITY STA'L'E "LIP CODE <br /> O <br /> R CHECK IIERE 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 /> 0 RODNEY SCHATZ <br /> NMAILJNG or STREET ADDRESSLODI, CALIF. 95 OWNER PHONE N(with area code) <br /> R CITY STATE ZIP CODE <br /> CIIHCK IIERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> .1. ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P EXEMPT FARM TANK,SITE (ALL.underground TANKS at site - to or < 1,10C gallon capacity) <br /> B 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 TANKSIZF. CHEMICALSSTORID ESTIMATfiD DATE LAST USED ME11iODOFCIASURB DATE OF REMOVAL Olt <br /> A (GALLONS) CIlI RENILY OIl PRP <br /> N vIOUSLY IF CURRENTLY EMPTY IF PERMANFNILY CLOSED CLASURE IN PLACE <br /> K <br /> I <br /> N <br /> F <br /> O <br /> THIS FOAM IIAS IIEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TUR BEST OF MY KNOWLEDGE,IS TRUE.AND CORIIF.LT. <br /> NAME J TITLE DATE?-_/ -� <br /> ORRICE USE ONLY <br /> SWE19'S0 OOMPN U)CCODLDISTCODENACI1VLUO-T I NPXEMPI'UGI' NCLOSEDUGTSWEEPSPRGM/SUECOUE UATIf <br /> Di 23 044 (12/88) <br />