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�JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FARM TANK INFORMATION FOR <br /> Fk+� asPF <br /> FACILITY/SITE INFORMATION (Complete this Form for each facility/site) y <br /> F SEP 5191 <br /> ARM or BUSINESS NAME ONTACT NAME <br /> ENVIRONMENTAL HFALTH <br /> I *DRESS (Street address of TANK Iocation) PHONE # WITH AREA CODeLH141 I /jl_ ( iCE7S' <br /> I -77 <br /> 2oq 6 Z40`� <br /> ITY V� TATE IP CODE EAREST CROSS STREET <br /> HASS� �y I Slidd r4 t4 <br /> ECK HERE i this ADDRESS shoulc6e used for Legal Notification <br /> OPERATOR INFORMATION & ADDRESS (Complete if Information Different from Above) <br /> AME OPERATOR CONTACT NAME <br /> AILING or STREET ADDRESS OPERATOR PHONE # WITH AREA CODE <br /> ITY TATE 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 OWNER CONTACT NAME <br /> X-77 14 <br /> I. 4 4AILING or STREET INFORMATION OWNER PHONE # WITH AREA CODE <br /> 7 7 9,3 z Rd a q 7 <br /> TY .-- l.1i11 I7i3°370 <br /> HECK HERE if thi ADDRESS should be used for Legal Notification ( 3S'0 X <br /> Check Appropriate Box <br /> CTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gal. capacity) <br /> XEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gal. capacity) <br /> ERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site renwved r closed in place) <br /> UNDERGROUND TANK INFORMATION (List Additional tank information on separate sheet if needed) <br /> TANK SIZE CHEMICALS STORED ESTIMATED DATE LAST USED MEHTOD OF CLOSURE DATE OF REMOVAL OR <br /> (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> I <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> IT ATE <br /> OFFICE USE 0 Y <br /> WEEPS # OMP # LOC CODE I DIST CODE # ACTIVE UGT # EXPEMT UGT # CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 10/89 <br />