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' t &OAOUIN COUNTY PUBLIC HEALTH SERVICES • <br /> UNDERGROUND STORAGE TANK PROGRAM - FARM TANK INFORMATION FORM RECEIVE <br /> FACILITY/SITE INFORMATION (Complete this Form for each faciiity/site) <br /> eARM or BUSINESS NAME CONTACT NAME €NVIRONMENTAL HEAL H <br /> thP' Robert Bogetti & Sons II Robert Bogetti PERMITIRRVICED <br /> LADDRESS (Street address of TANK location) HONE # WITH AREA CODE <br /> 4 700 W Linne Road 209-832-2205 <br /> 4 ITY TATE QIP CODE EAREST CROSS STREET <br /> Tracy CA 1 95376 1 Koster Road <br /> HECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION & ADDRESS (Complete if Information Different from Above) <br /> NAME PERATOR CONTACT NAME <br /> 4 .AILING or STREF'T ADDRESS OPERATOR PHONE # WITH AREA CODE <br /> ITY11 iA iE IP CODE <br /> HECK HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION & ADDRESS (Complete if Different from Above) <br /> AME W'NER CONTACT NAME <br /> Robert Bogetti & Sons II Robert Bogetti <br /> A RING or STREET INFORMATION WNER PHONE # WITH AREA CODE <br /> P.O.Box 797 209-832-2205 <br /> :ITY TATE IP CODE <br /> Vernalis ICA 195385 <br /> X HECK HERE if this ADDRESS should be used for Legal Notification <br /> Check Appropriate Box <br /> CTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gal. capacity) <br /> EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gal. capacity) <br /> XX ERMANENTLY 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 /> TANK SIZE CHEMICALS STORED STIMATED DATE LAST USED MEHTOO OF CLOSURE DATE OF REMOVAL OR <br /> (GALLONS) CURRENTLY OR PREVIGUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> I 500 DieselI Removed 7-15-92 <br /> 450 Gasoline Removed 7-15-92 <br /> 250 Gasoline Removed 7-15-92 <br /> L NO OTHER UNDERGROUND TANKS 0 RANCH <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> AME [TLE <br /> � ATE <br /> Partner 9-2-92 <br /> OFFICE USE ONLY <br /> LL6WEEPS # OMP # I LOC CODE DISI CCAE I # ACTIVE UGT EXPENT LOT CLOSEO UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 10/89 <br />