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Underground Storage Tank Program - Farm Tank Information Form <br /> FACILITYIcSITE INFORMATION (Complete this form for each FARM TANK location.) <br /> FARM or BU�}NESS NAME CONTA f NAME <br /> A ?, A , Pt - -ke� �r/a No dsev t-1 Qn <br /> C ADDRESS(Street address� of TANK 1 tion) PHONEY (with a ca code) <br /> L 'LZD .V, ft!J Z 20-36 <br /> CITY p STATE ZIP CODE NEAREST�CROSS S1REG1' <br /> T UGC C c( vJ oZ ,! 4 V1 5 <br /> Y I CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete If Information different front above.) <br /> O Nr / OPERA'1ItCONTACI'NAME <br /> A <br /> E MAI NO or OPERATOR PI TONE M (with area code) <br /> A ' 6 �e ries ?PI -360-5j'61 <br /> T CITY STATE ZIP CODE <br /> Lodi. say s� <br /> R I CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete If different from above.) <br /> NAME OWN IRC 'I'ACI'NAML <br /> G V,�ltej v 4 Na 14 J l�( <br /> NMAILING orWREST ADDRESSOWNER PHONE N(with area code) <br /> E ► � 020 -3 mss— G / <br /> R CITY ' srA•rE ZIP CODE <br /> If. 6 �S(] <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P X EXEMPT FARM TANK SITE (ALL underground'fANKS at site = 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 addltloaal tank Information on separate silent If needed.) <br /> T TANK SIZE CHEMICALS STORED ESTIMATED DATE LAST USED M[:n IOD OF CIASURE DATE OI+REMOVAL Olt <br /> A (GALLONS) CIM IINILY OR PREVIOUSLY IF CURIIPNI'LY EMPTY IF PERMANENTLY CLCYiED CI.USURI'.IN PIACE <br /> N <br /> K .J Lo �f <br /> N <br /> F <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TILE HEST OF MY KNOW LEIIGF IS TRUE AND CORREC71% <br /> NAME TITLE ,q( DA'ITi <br /> OFFICE USE ONLY <br /> SWEEPS 0 COMP a IACCODE DIST CODE s ACI1V1i lluI rI EKL7.IP1'UG'1' N CLosw UGI' Sww m Fl1GMISUU CODE UA'I'li <br />