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_ Underground Storawank Program - Farm Tank I*mation Form <br /> 'FACILITY/RITC INFORMATION (Complete this form for cacti FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAMB <br /> A Charles R. Alcock <br /> C ADDRESS(Street address of TANK location) PHONEY (with area code) <br /> 1 5971 11 Linne Rd. (209) 835-1919 <br /> L <br /> 1 CITY STATE ZIP CODE NCAItEST CROSS STREET <br /> T Tracy CA 95376 Banta Rd. <br /> YXX CIIECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORNIATION&ADDRESS (Complete if information different from above.) <br /> . i <br /> 0 NAME OPERATOR CONTACT NAME <br /> P <br /> S MAILING or STREET ADDRESS OPERATOR PHONE Y (with area code) <br /> R <br /> A <br /> T CITY STATE ZIP cope <br /> 0 <br /> R CHOCK IIERC is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION&ADDRESS (Complete If different from above.) <br /> NAME OWNER CONTACT NAME <br /> 0 <br /> NMAILING or STREET ADDRESS OWNER PHONE Y(with area code) <br /> E <br /> R CITY STATE ZIP CODE - <br /> CHECK AERO if this ADDRESS should be used for Legal Nolificaiion <br /> CIIECKAPPROPRIATE BOX <br /> .I. ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P XX EXEMPT FARM TANK SITE (ALL underground TANKS at site,a to or < 1,100 gallon capacity) <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) CULL E T'LYORPRE-VIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K 4000 Dicsl April 1989 May $ 1989 <br /> 1 330 Unleaded Gas <br /> N 550 Unleaded Gas <br /> F <br /> 01.. <br /> TICIS FOIihil �Ew' COMjLE'rCD UNDER PENALTY FPCIUURY,AND TO Tl1Enw OF MY KNOWLEDGE.+ IS TRUCANDCORRECT. <br /> NAME 77TLG Owner DATE <br /> 5/2678T] <br /> OFFICE USE ONLY <br /> SWEEPS. COMPO LDCCODE DISTCODEIIACTIVEIoT If EXEMPT UGT MCLOSED UGT SWEC•I'S PRGMiSUDCODE DATE ' <br />