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SAN AQUIN LOCAL HEALTH DIT ZICT <br /> UNDERGROuhd STORAGE TANK PROGRAM - FARM TANK INFORMATION FORM <br /> FACILITY/BITE INFORMATION (compiate this For@ for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> C ADDRESS (Street address of TANK location) PHONE 1 mrT" AmaA coos <br /> 1 j <br /> L <br /> Y CITY STATE 111' CODE NE CROSS STREET <br /> CNECR RERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION 1 ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE I D'T" AREA cooE <br /> R <br /> A <br /> T <br /> 0 CITY STATE 11P CODE <br /> k <br /> CNECI RERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION W ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> / G L /iS T /7 1,fZ'A T C !7'f D <br /> O MAILIN6 or STREET ADDRESS OWNER PHONE I MRN AaEA CODE <br /> E 11134 /-7- <br /> R CITT- ATE 11P CODE <br /> - l�( if " <br /> DRECR HERE if this ADDRESS should be used for Legal Notification <br /> CAec) h1proAriate i)aa <br /> i 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 a to or ( 1,100 gal. capacity) <br /> E <br /> x*t 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 SIZE 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 /> 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 TITL <br /> DATE_- <br /> OfffCE USE oily <br /> SWEEPS 1 COMP 1 fLOC CODE OIST CODE 1 ACTIVE UGT 1 EXEMPT UGT I CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 (12/88) <br />