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SAISQAQUIN LOCAL HEALTH U&RICT <br /> UNDERGROUND 610RA6E TANK PROGRAM - FARMANK INFORMMION FORM <br /> fAC1LITV/BITE INFORMATION (Complete this fore for lith FARM TANK 1oCAticn) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> f Mohammed Malik Dale Jolley <br /> A <br /> C ADDRESS (Street address of TANK location) PIIOHE 1 "� AA{A co°. <br /> L 6550 E. Hwy 12 (209)334-1402 <br /> 1 <br /> f CITY SfAIE IIP CODE NEARESI CROSS STREEI <br /> YJ Lodi CA 95240 Techlenberg <br /> CNECI NERE if this ADDRESS should be used for Legal Notilication <br /> OPERATOR INFORMATION 1 ADDRESS (Coeplele If Information Dillerenl from Above) <br /> NAME OPERATOR CflNIACf NAME <br /> 0 Mohammed Malik Dale Jolley <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 Y11 "°S" C°°` <br /> R <br /> A 1222 Cedar Creek Ct. (913)661-9972 <br /> 0 CITY STATE ZIP CODE <br /> R Modesto, A 95355 <br /> X CNECI NERE if this ADDRESS should be used for legal Notification <br /> PROPERTY OWNER INFORMATION 1 ADDRESS (Complete If Different from Above) <br /> MANE OWNER CONTACT NAME <br /> Same as above <br /> 0 MAILING or STREET ADDRESS OWNER PIIONE 1 WITH AALA CAPE <br /> U <br /> N <br /> R CITY STATE IIP CODE <br /> CNECI NERE it this ADDRESS should be used lot legal Notification <br /> CAeei IFFraptiale Nor <br /> 1 ACTIVE FARM TANK SITE (Dns or more underground TANKS ) 1,100 gal. capacity) <br /> Y <br /> P X 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 bite renewed or closed in place) <br /> UNDERGROUND TANK INFORMATION (List Additional lank information on separate sheet it needed) <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 /> H <br /> K unknown gasoline unknown removal 1/8/97 <br /> B1,C)00 gasoline unknown removal 2/13/97 <br /> F <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY Of PERJURY, AND TO THE BEST Of NY KNOWLEDGE, IS TRUE AND CORRECT <br /> WANE , I j ; c , TITLE owner DATE 3/i 1/7� <br /> OFFICE off ONIy <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE 1 ACTIVE UGT 1 EXEMPT UGI 1 CLOSED UGI SWEEPS PR6MISUD CODE DAIS <br /> i <br /> EH 23 044 112/88) <br />