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-*3a y <br /> SAN JE )UIN LOCAL HEALTH DIST CT <br /> UNDER GRDUNO STORAGE TANK PROGRAM EARN TANK INFORhATION <br /> FACILITY/UTE INFORMATION (Completm thio fon for each FARM TANK location) V <br /> FARM or BUSINESS NAME CONTACT NAME 1 19fJ <br /> Mr. Robert K. Fer us v��Of"`z' <br /> F Ferguson Farms Inc. g v'7 <br /> A --�-- «Ir« a«aA tout — ;,'4VICfS Tlf <br /> C ADDRESS (Street address of TANK location) PHONE f <br /> 1 <br /> L 14333 W. Clifton Court Rd. 209/465-9828 <br /> 1 <br /> T CITY STATE 11P CODE NEAREST CROSS STREET <br /> Y Stockton CA 95206 Tracy Blvd. <br /> CHECK NEJE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION i ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> AFAILING or STREET ADDRESS OPERATOR PHONE I <br /> R <br /> 1 <br /> O <br /> k CITY SIATE IIP CODE <br /> CNECL YELE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION B ADDRESS (Completm If Different from Above) <br /> NAME OWNER CONTACT NAME <br /> Mr. Robert E. Ferguson <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 "IT" AREA coo& <br /> W <br /> N 7436 Meadow Ave. 209/465-9828 <br /> E <br /> N CITY SIATE I;P Tf <br /> Stockton CA 5 <br /> g CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CAect Itpopiete !ar <br /> T ACTIVE FARM TANK SITE (One or bore underground TANKS > 1,100 gal. capacity) <br /> Y <br /> P EIEMPT FARM TANK SITE (ALL underground TANKS at site • to or ( 1,100 gal. capacity) <br /> C <br /> X PERNANENTLY 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 SIX 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 /> H <br /> K 1500 Gasoline (Reg.) 11/84 Removal 11/84 <br /> 1 <br /> N <br /> F <br /> ll <br /> THIS FORM HAS BEEN COMPLET D UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME g TITLE paTE <br /> Ma <br /> Mr.Woe lz r u`soh' V.P. Ferg oson Farms 15 89 <br /> OFFICE USE OILY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE t ACTIVE UGT11�11111 111 11 CLOSF.p U11 SWEEPS 11117SUb CODE DATE <br /> EH 23 044 (12188) <br />