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SAN .7'-IAQU1N LOCAL HEALTH DISTRICT <br /> UNDER696„ STORAGE TANK PROGRAM - FARM TANK INFORMATb... ORM <br /> FACILITY/BITE INFORMATION (Complete this Fon for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> � r � <br /> A� � O — d <br /> C DRESS !Street address of TANK location) PHONE B WITH AA"A CDD" <br /> T STATE IIP CODE NEAREST CROSS STREET <br /> CITY <br /> Y f }�' QJ <br /> CAECA MERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION L ADDRESS (Complete if Information Different from Above) <br /> NAI OPERATLI CONTACT NAME <br /> P <br /> T. <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 WITH A"A CODs <br /> T —� vVf T� >/ <br /> 0 CITY STATE IIP CODE <br /> R ti1 70/ (' R1 rj 'it. (. <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION Z ADDRESS (Complete if Different from Above) <br /> NAM€ OWNER CONTACT NAME <br /> 'o Sc n' <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITH A"[A CDD" <br /> E3a71 S �IQ � ;Tr /��f, � <br /> R CIL STATE IIP CODE <br /> il0 (k).- "a} D <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> Check APPropriate Box <br /> Y ACTIVE FARM TANK SITE (One or more underground TANKS ) 1,100 gal. capacity) <br /> P 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 SITE 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 /> N' r' L1 <br /> F <br /> THIS FORM N COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME <br /> TI TL DAT <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP t LOC CODE DIST CODE11 ACTIVE U6T 1 EXEMPT UGT t CLOSED UGT SWEEPS PREM/SUB CODE DATE <br /> _____j <br /> EH 23 044 (12/88) <br />