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/JILT SAN J.,,DrJIN LOCAL HEALTH DISI%wwr.T <br /> UNDERGROUND STORA6E TANK PROGRAN - FARM TANK TNroRMATIDN FORM <br /> FACILITY1811E INFORMATION (Complete this Fon for uch FARM TANK location) <br /> FARM or BUSINESS NAMECONTACT NAME <br /> A �'- 10 7 e_ '' �S <br /> C ADDRESS (Street ddress of TANK local ) PHONE 1 WITH �.a• Cana <br /> 1 �/ 70(v <br /> L - 33 3 /uS <br /> I <br /> T CItY STATE ZIP CODE NEAREST CROSS STREET <br /> Y <br /> M � -LLti <br /> ✓ CRlCI N(Rf if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION i 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 AEE• CODE <br /> R <br /> A <br /> 1 <br /> 0 CITY STATE 11P CODE <br /> R <br /> CN(Cf REif if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION i ADDRESS (Complete If Different from Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITH An" CooE <br /> W <br /> x <br /> E <br /> R CITY STALE11P CODE <br /> CNlCE NEIt if this ADDRESS should be used for legal Notification <br /> CAec) 11pre/ri4te iaa <br /> T ACTIVE FARM TANK SITE (One or more 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 /> C <br /> PERMANENTLY CLOSED FARN 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 /> f 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 /> 1 <br /> N O �� <br /> 0 0 ° <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME •�Jr Jew ' TITLE DATE <br /> Off ICE USE ONi <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE t ACTIVE UGI 1 EXEMPT UGT 1 CLOSED UG1 SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 112188) <br />