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SAN .T'IAQUIN LOCAL HEALTH DISTRICT <br /> ONDERGRs _ STORAGE TANK PROGRAM - FARM TANK INFORMAi ;ORM <br /> FACILITY/BITE INFORMATION (Complete thie Fon for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F Wayne C. Castle same <br /> A <br /> C ADDRESS (Street address of TANK location) PHONE 1 WITH AREA COOK <br /> � 6106 E. French Camp Road (209) 982-1641 <br /> T CITY STATE TIP CODE NEAREST CROSS STREET <br /> Y Manteca ( A 95336 <br /> H <br /> NECI NEAE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION L 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 AREA CODE <br /> R <br /> A <br /> 0 CITY STATE ZIP CODE <br /> R <br /> CNECA NEAE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION 4 ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITH AREA CODE <br /> W <br /> N <br /> F. <br /> R CITY STATE 111` CODE <br /> CAECA HERE if this ADDRESS should be used for Legal Notification <br /> Chat Appropriate Box <br /> T ACTIVE FARM TANK SITE (One or sore underground TANKS ) 1,100 gal. capacity) <br /> Y <br /> P X EXEMPT FARM TANK SITE (ALL underground TANKS at site to or ( 11100 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 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 550 gasoline S1/313 Tank Removal 5/13/93 <br /> N <br /> 0 <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 /> OfffCE USE 001 <br /> SWEEPS 1 CONP 1 LOC CODE DIST CODE 1 ACTIVE UGT 1 EXEMPT UGT 1 CLOSED UGT SWEEPS PRGM/SUB CODE GATE <br /> IN 23 044 (12/80) <br />