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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> NKR- STORAGE TANK PROGRAM - FARM TANK INFORM/ ORM <br /> FACILITY/SITE INFORMATION (Complete this Fore for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> FJ <br /> A <br /> C ADDRESS (Street address of TANK location) PHONE i WITH AREA coos <br /> L Alolc) h FC/a- � <br /> T CITY _ STATE IIP CODE NEAREST CROSS STREET <br /> Y <br /> CHECK HfRf if this ADDRESS should be used for legal Notification <br /> OPERATOR INFORMATION Z ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 if"c(S <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 WITH AREA CODE <br /> e. <br /> LA <br /> STATE IIP CODE <br /> fRf if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION Q ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITH AREA CODE <br /> W <br /> N <br /> E <br /> R CITU STATE IIP CODE <br /> CHECX HERE if this ADDRESS should be used for Legal Notification <br /> Chect Appropridtf Box <br /> T ACTIVE FARM TANK SITE (One or bore underground TANKS ) 1,100 gal. capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE ✓ (ALL underground TANKS at site x 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 /> uH.^";=�Rv"J';D ThnN inFL'A. I Tura (Li S: Auuiiiuu6l tdilR 16fOfmdtl0fi On Sepirdie sheet it needed) <br /> T TANK SHE 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 /> K 7z> <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, IS TRUE AND CORRECT <br /> ,NAME ff ��� TITLE DATE <br /> h7 uti <br /> OfflCf USE ONLY <br /> SWEEPS 1 COMP f LOC CODE DIST CODE11 ACTIVE UGT f EXEMPT UGT 1 CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 (12/88) <br /> 000gAL,-ga' � <br />