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SAN J QUIN LOCAL HEALTH DIST'- TCT <br /> UNDERGROUhti STORAGE TANK PROGRAM - FARM TANK INFORMATIOn--JRN <br /> FACILITY/SITE INFORMATION (Complete We Fon for each FARM TANK locatlon) <br /> FARM or BUSINESS NAME CONTACT N E <br /> A <br /> A <br /> C ADDRESS (Street address of TANK location) PHONE Mr*M "AEA CDDA <br /> Ig <br /> Y CITY STATE 11P CODE NEAREST CROSS STREET <br /> 226 . <br /> CEI NERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION L ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> P — <br /> E MAILING or STREET ADDRESS OPERATOR PHONE I WITH AREA CODE <br /> R <br /> A <br /> T <br /> 0 CITY STATE 11P CODE <br /> R <br /> fHICI YEAS if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION A ADDRESS (Complete if Different from Above) <br /> NAME OWNED ONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 Mr1M AAEA CODE <br /> W q J� <br /> E 7 / L LCt �V' ) <br /> RCl�) SAT iJpC <br /> HECI ME if this ADDRESS should be used for Legal Notification <br /> Checl -Colt <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS ) 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 SITE 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 �, <br /> r �� d <br /> PJL S <br /> N y/ao�J 9. <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 /> fL_r I-', <br /> OFFICE NSf ONLY <br /> 'SWEEPS 1 COMP 1 LOC CODE DIST CODE 1 ACTIVE UGT 1 EXEMPT UGT 1 CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 (12/88) <br />