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Underground Stora*,e Tank Program - Farm Tank, ,,ormation Form <br /> FACIIATY/SITE 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# (with area code) <br /> I <br /> L <br /> I CITY STATE I ZIP CODE NEAREST CROSS STREET <br /> T <br /> Y 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 /> IRI I CHECK HERE is this ADDRESS should he used for Legal Notification. <br /> PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) <br /> NAME RODNEY SCHATZ OWNER CONTACT NAME <br /> O <br /> AEPINE RD. <br /> N MAILING or STREET ADDRESS LODI, C 446400 N.ALIF. 95240 OWNER PHONE#(with area code) <br /> E <br /> R CITY STATE I ZIP CODE <br /> CHECK HERE 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 EXEMPT FARM TANK SITE ( E 8 capacity) <br /> P ALL underground TANKS at site = to or < 1,I00 gallon ca acit <br /> E 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 /> N <br /> K -!VO Gf}S J2� <br /> I <br /> N <br /> F <br /> O <br /> 1 1 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME TITLE © DATE <br /> OFFICE USE ONLY <br /> SWEEPSN ODMP# I IOC CODE DIST CODE#ACTIVE UGT I #EXEMPT UGT #CLOSED UGT SWEEPS PRGM/SUB CODE <br /> FH 23 044(12/88) <br />