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SAN JOAQUIN LOCAL HEALTH DIF RICT <br /> 'N ER 1 PRO <br /> STORA6E TANK GRAM - FARM TANK INFORM1b FARM <br /> FACILITY/SITE INFORMATION (Co►plete thio Fora for each FARM TANK location) 4 <br /> FARM or BUSINESS NAME CONTACT NAME <br /> ADDRESS (Street address of TANK location) PHONE 1 WITM AwIA Cone <br /> Lk <br /> cL fS <br /> T CITY ATE IIP CODE NEAREST CROSS STREET <br /> r -j kIQ FL),-, nck. <br /> CNECI NERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION i ADDRESS (Complete if Information Different from Above) <br /> 0 NAME OPERATOR CONTACT NAME RFC�JV�D <br /> P <br /> R MAILING or STREET ADDRESS OPERATOR PHONEFp V-TM " 1. °°mm <br /> A <br /> T E�N"'fNr <br /> R CITY STATE IIP CODE Q - 17sA[Ty <br /> CNECC NERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER ihFORM MON 1 ADDRESS (Complete If Different (roe Above) <br /> E <br /> OWNER CONTACT NAME <br /> STREET ADDRESS OWNER PHONE 1 WITH .=C• Cooc <br /> NERE if this ADDRESS should be used for Legal Notification <br /> Chat AJpopFiete Box <br /> Y ACTIVE FARM TANK SIZE (One or sore underground TANKS > 1,100 gal. capacity) <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or ( 11100 gal. capacity) <br /> E <br /> PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site emoved r closed in place) <br /> UNDERGROUND TAMK INFORMATION Rist Additional tank info. <br /> aticn cn Separate ;beet if neE„ed) <br /> T 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 /> K -, <br /> 1 1 <br /> N -SCI <br /> 1- <br /> THIS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME TITLE DATE <br /> OFFICE USE ONLY I <br /> SWEEPS 1 COMP 1 LOC COOT CODE t ACTIVE UG1 1 EXEMPT UGIf1 CLOSED UGTI SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 (12188) <br />