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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FARM TANK INFORMATION FORM - - <br /> FACILITY/SITE INFORMATION (Complete this Form for each facility/site) <br /> ARM or BUSINESS,NAME CONTACT NAME <br /> .- 39'G 4� <br /> 1 DDRESS (Street address of TANK location) PHONE # WITHAREA CODE F <br /> .� f <br /> I <br /> L <br /> ITY _ TATE IP CODE EAREST CROSS STR,�ET <br /> - <br /> HECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION 8 ADDRESS (Complete if Information Different tram Above) <br /> AME PERATOR CONTACT NAME <br /> AILING or STREET ADDRESS DPERAIDR PHONE # WITH AREA CODE -�J <br /> ITY TATE IP CODE <br /> HECK HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION 8 ADDRESS (Complete if Different from Above) <br /> AME WNER CONTACT NAME <br /> AILING or STREET INFORMATION 3WNER PHONE # WITH AREA CODE <br /> ITY TATE IP CODE <br /> HECK HERE if this ADDRESS should be used for Legal Notification <br /> Check Appropriate Box <br /> DTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gal. capacity) <br /> %EMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gal. capacity) <br /> ERMANENTLY 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 /> TANK SIZE CHEMICALS STORED STIMATED DATE LAST USED MEHTOD OF CLOSURE DATE OF REMOVAL OR <br /> (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> I <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> AME ITLE ATE T <br /> —i <br /> FICEUSE ONLY <br /> WEEPS # OMP # LOC CODE DIST CODE # ACTIVE UGT # E%PEMT UGT # CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 10/89 <br />