Laserfiche WebLink
SAN 4QUIN LOCAL HEALTH DIF `ICT <br /> UNDERGROmm STORAGE TANK PRO DAM FARM TANK INroRMAnn,T FORM <br /> FACILITY/BITE INFORMATION (COeplete this Fore for each FARM TANK location) <br /> FARM USINESS NA CONTACT <br /> A #1 <br /> C ADDRESS (Street address of TA location) PHONE 1/w1Tx AREA coag <br /> I GPCO�� <br /> T CIT <br /> Y NEARE OSS STREET <br /> PAS` <br /> CHECf HERE it this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION i ADDRESS (Complete if Information Different from Above) <br /> [MAILING <br /> OPERATOR CONTACT NAME <br /> or STtADDRESS OPERATOR PHONE I NITN AREA CODE <br /> STATE ZIP COOS <br /> CRECI HERshould be usedfor Legal Notification <br /> PROPERTY OWNER INFORMATION H ADDRESS (Complete if Different from Above) J014' 2 9 1989 <br /> NAME (1 OWNER CONTACT NAME <br /> saw� Ew�PERNIIT I SERVICES HEALTH <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 NIT" AREA CooE <br /> W <br /> N <br /> E <br /> R CITY STATE IIP CODE <br /> Cwl HERE if this ADDRESS should be used for Legal Notification <br /> Chea Appropriate bar <br /> T ACTIVE FARM TANK SITE (One or sore underground TANKS > 1,100 gal. capacity) <br /> Y <br /> EP 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 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 /> K t0600 Air rd! A'pyj&1,ek <br /> N O O T <br /> F <br /> THIS 06M HAS EE COMPLETED R PENALTY OF PERJURY, AND 10 THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> NAME TITLE DAT �� <br /> OFFICE USE OILY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE 1 ACTIVE UGT 1 EXEMPT UGT 1 CLOSED UGI SWEEPS PRGM/SUB CODE DATE <br /> EH 23 044 (12188) <br />