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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGR( -STORAGE TANK PROGRAM - FARM TANK INFORMAT <br /> FACILITY/SITE INFORMATION (Complete this Fore for each FARM TANK location) <br /> FARM or BUSINESS NAME CONTACT NAME D �"I�9, I�I11 <br /> F ((v' t, u <br /> A <br /> C ADDRESS (Street address of TANK location) PHONE 1 MIT" mak CODE <br /> i JU�� 21989 <br /> 1 D• � �.1�L{ y�� _ � AFI <br /> YCITY 11�E IIP CODE NEAREST CR S STREET EN`�pERTATI I SER`/ICES <br /> CNECX MERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION L ADDRESS (Complete if Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 WITH AREA COOP <br /> R <br /> A <br /> T <br /> 0 CITY STATE 11P CODE <br /> R <br /> CNECX MERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION i ADDRESS (Complete if Different from Above) <br /> NAME OWNER CONTACT NAME <br /> 0 MAILING or STREET ADDRESS OWNER PHONE N WITH ARCA Coos <br /> W <br /> N <br /> E _. <br /> R CITY STATE IIP CODE <br /> CNECX SERE if this ADDRESS should be used for Legal Notification <br /> cbect ippropriate Nor <br /> T ACTIVE FARM TANK SITE (One or sore underground TANKS ) 1,100 gal. capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site to or ( 1,100 gal. capacity) <br /> E <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 S11E 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 /> K <br /> 1 <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 TITLE DATE <br /> ,au,�un <br /> OFFICE ISE ONLY <br /> 1 LOC CODE DIST CODE14 ACTIVE UGT 1 EXEMPT USTI# CLOSED UGT SWEEPS PRGM/SUB CODE DATE <br /> ffKfi <br /> EN 23 044 (12/88) <br />