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SAN ' 'AQLJIN LOCAL HEALTH DI' QICT <br /> UNDERGRyz, D STORAGE TANK PROGRAM - FARM TANK INFORMATION FORM <br /> FACILITY/BITE INFORMATION (Complete this Fore for uch FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME <br /> C ADDRESS (Street address of TANK location) PHONE 1 WITH AREA Coot <br /> I <br /> T CITY _ STATE IIP CODE NEAREST CROSS STREET <br /> Y ` �6-/"- 'i4 llSyc7 <br /> CHECK JIM 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 /> E MAILING or STREET ADDRESS OPERATOR PHONE I WITH ARCA Coo" <br /> R <br /> A <br /> T <br /> 0 CITY STATE11P CODE <br /> R <br /> CNECI NERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION 1 ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITH AREA Coo" <br /> W <br /> E � lot <br /> R CITY S1'TE 21P CODE <br /> GNECI SERE if this ADDRESS should be used for Legal Notification <br /> Chert RipaPrlate Bar <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS ) 1,100 gal. capacity) <br /> Y <br /> E S% EXEMPT FARM TANK SITE (ALL underground TANKS at site to or ( 1,100 gal. capacity) <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 /> Z- <br /> N <br /> F <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND 10 THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME TIT c-? DATE. _ <br /> OfffCE HE ONLY <br /> SWEEPS I COMP 1 LOC CODE DIST CODE t ACTIVE UGT 1 EIEMPT UGT 1 CLOSED UGT SWEEPS PR6M/SUB CODE DATE <br /> EN 23 044 (11/88) <br />