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SAN JOn.dUIN LOCAL HEALTH DISTI,.,:T <br /> UNDERGROUND STORAGE TANK PROGRAM - FARM TANK INFORMATION FORK <br /> FACILITY/SITE INFORMATION (Coaplate thle Fore for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F UkS1--5rcyw FF!/RMS RPo37, c, wesrsr �/ <br /> A <br /> C ADDRESS (Street address of TANK location) PHONE 1 WITH ANSA C009 <br /> .225473 S'O, HSG141_RAfD HUE, (20q) 599 - 5 r 93 <br /> Y CITY aj T PDN STATE IIP CODE NEAREST CROSS STREET <br /> CTn 9__34 6 J DNE RD <br /> ✓ CHFCI HIRE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION I ADDRESS (Complete if In(oraation Differant We Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE I NIT. ANCA CODE <br /> R <br /> A <br /> T <br /> 0 CITY STATE 11P CODE <br /> k <br /> CNFCI ME if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION I ADDRESS (Cosplete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE I WITH AREA COOK <br /> W <br /> N <br /> E <br /> k CITY STATE IIP CODE <br /> IHECI NERF if this ADDRESS should be used for Legal Notification <br /> Chtel ARAroprietm box <br /> T ACTIVE FARM TANK SITE One or sore underground TANKS ) 1,100 gal. capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site to or ( 1,100 gal. capacity) <br /> E <br /> PERMANENILY CLOSED FARM TANK SITE (ALL underground TANKS at site sov 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 OFAOR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSUR E <br /> N <br /> K <S'&&V GASo[zME S is' 8 9 S' �9 g <br /> H 5 nz�s �c Fahr: <br /> F <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT <br /> NAMEd TITLE DATE `7_C--G/ G :i <br /> OFFICE USE ORIy <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE 1 ACTIVE UGT t EXEMPT UGIII CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 (12188) <br />