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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE: <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 /> O 6clrvvG' /3r,,j►f r S doP- 0rh <br /> I DRESS (Street address of TANK location) PHONE # WITH AREA CODE <br /> �ITY �� <br /> TATE �IP E �EAREST CROSS STREET <br /> �x o5 <br /> HECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION & ADDRESS (Complete if Information Different from Above) <br /> AME PERATOR CONTACT NAME <br /> CLING or STREET ADDRESS PERATOR PHONE # WITH AREA CODE <br /> ITY TATE IP CODE <br /> NECK HERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION & ADDRESS (Complete if Different from Above) <br /> AME WNER CONTACT NAME <br /> ILING or STREET INFORMATION DWNER 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 /> CTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gal. capacity) <br /> XEMPT 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 /> SG�LJ <br /> (GAL..LIONS) CURRENTLY OR PREVIOUSLY 1F CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> q <br /> 716 el) ar G'li�t! i1 <br /> f <br /> THIS FORM HM BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> AME <br /> 1 E ATE/ <br /> OFF1l USE ONLY <br /> WEEPS # OMP # LOC CODE DIST CODE # ACTIVE UGT # EXPEMT UGT # CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> -X2 32 GH ,9/ J %Z 23,22— <br /> EH <br /> .3.22—EH 23 044 10/89 <br />