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SAN JOA' IN LOCAL HEALTH DISTR T <br /> y� � <br /> UNDERGROUND SGE TANK PROGRAM - FARM TANK INFORMATION f�' <br /> FACILITY/BITE INFORMATION (Complete this Fon for etch FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> C ADDRESS (Street address of TANK location) PHONE 1 WITH AREA Coua <br /> 1 , <br /> l <br /> T CITY STATE 21P CODE NEAREST CROSS STREET <br /> Y �5b Nr{ G <br /> CHECK HERE 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 AREA Coua <br /> R <br /> A <br /> T <br /> 0 CITY STATE 21P CODE <br /> R <br /> CHECK HERE if this ADDRESS should be used for Legal Notification - <br /> PROPERTY OWNER INFORMATION b ADDRESS (Complete if Different from Above) p� u <br /> NAME OWNER CONTACT NAME <br /> w <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITH AACA Cooc } <br /> W .. �c <br /> N <br /> C.- ZE <br /> E <br /> R CITY STATE 11P CODE I LJ <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> tAect Appropriate dor <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 /> E <br /> 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 SITE 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 �y <br /> K .336 c — Y U v l c SF ho rvlJ t— o <br /> I <br /> N <br /> F <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY Of PERJURY, AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT <br /> NAME TITLE DATE <br /> DOW USE DHL 1 <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE11 ACTIVE UGIJI EXEMPT UGT I CLOSED UGT SWEEPS PRGM/SUB CODE I DATE <br /> EH 23 044 (12/88) <br />