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SANOAQIJ I N LOCAL HEALTtI D O R ICT <br /> UNDERGROIINO STORAGE TANK PROGRAM - FARM TANK INFORMATION FORM <br /> FACILITY/SITE INFORMATION (Complete this Fore for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> A <br /> A <br /> C ADDRESS (Street address of TANK location) PHONE 1 WITH ADDA COOK <br /> TIcx--t\j0YL 0- Ocll 333 - V7Vo <br /> I CITY �� S,[ATE ZIP CODE NEAREST CRO SIREEj <br /> Y ) Z ,1 Z LO i N1/F <br /> CHECK NEIE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION It ADDRESS (Complete it Inlorutlon Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE I WITH AREA CODE <br /> i A <br /> T <br /> 0 CITY SATE i1P CODE <br /> R <br /> CNECf NEIE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION V ADDRESS (Complete it Different from Above) <br /> NAME OWNER CONTACT NAME <br /> SCz &- --Q—, <br /> 0 MAILING or STREET ADDRESS OWNER PHONE i WITH AREA CODE <br /> N � ]01� �' � FN �I /< D�- ���� � 333 - 8 -7 (0 <br /> F. <br /> R CITY �I STATE IIP CODE <br /> CA c � L�{ L <br /> CNECI Ulf if this ADDRESS should be used for LegalNotification <br /> g <br /> Check Appropriate /or <br /> I ACTIVE FARM TANK SITE (One or more underground TANKS ) 1,100 gal. capacity) <br /> V <br /> PEXEMPT 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 /> UNDER6ROUND TANK INFOROMATION (List Additional tank inforaation Cn separale sheet it needed) <br /> I 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' <br /> N h1,td e J .y/L IVIC7 <br /> F <br /> 01 1 71 <br /> �Zhi/1 y�r�c <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTYOfPERJURY, AND lO THE B T OF NY KNOWLEDGE, IS TRE AND CORRECT <br /> NAME J7n1�/ TITLE Dul)iV�I� DATE <br /> Off lCf E�U^5f ONIY � /J <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE[i ACTIVE UGT t EXEMPT UGT 1 CLOSED UGI SWEEPS PRGM/SUB CODE GATE <br /> EN 23 044 (12/00) <br />