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SAN J QUIN LOCAL HEALTH DIICT ` <br /> N R 1 OR NK PRO G� - FARM TANK INFORMATIL1rfORM <br /> FACILITY/SITE INFORMATION (Complete this Fon for each FARM TANK location) J U n (G 1989 <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F Ei IlOT''WENTAL HEffF <br /> A <br /> 9N/l GG �� T�SFfibdFkr/=/J <br /> C ADDRESS (Street address of TANK location) PHONE t WITH AmmA came <br /> L 1360 (.ci.4/ar c-7 f/; �;zOy ) c - & 23 -31 7 <br /> I <br /> T CITY STATE ZIP CODE NEAREST CROSS STREET <br /> t CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION W ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 !9 a ! <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE I WITH AREA CORE <br /> 0 <br /> A <br /> T — <br /> 0 <br /> R CITY STATE ZIP CODE <br /> CNECI HEAE if this ADDRESS should he used for Legal Notification <br /> PROPERTY OWNER INFORMATION Ii ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> O MAILING or STREET ADDRESS OWNER PHONE i R'TR AREA coOE <br /> W <br /> N <br /> F. <br /> R CITY STATE ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> Chest Appropriate Dox <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS y 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 SUE 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 /> KSUGG <br /> - �5 r /1'rr7 <br /> N <br /> F <br /> 0 <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 /> OFFUE USE ONLY <br /> SWEEPS i COMP 1 LOC CODE DIST CODE I ACTIVE UGT I EXEMPT UGT I CLOSED UGT SWEEPS PR6M/SUB CODE DATE <br /> Ell 23 044 (12/88) <br />