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SAN .7OUYN LOCAL HEALTH DIS4C:T <br /> Np R ROUND S(ORAGE TANK PROGRAN - FARM TANK 1NF08NATT2N fnRM <br /> FACILITYISITE INFORMATION (Coeplete this Fore for each FARM TANK location) <br /> [ADDRESS <br /> RM or BUSINESS HANE CONTACT NAME <br /> F <br /> A n �.�; <br /> C (Street address of TANK location) PHONE I rirn ANSA coo. <br /> I .. <br /> L <br /> 11:1; ') C <br /> T CI(Y STATE IIP CODE NEAREST CROSS STREET <br /> Y <br /> CHECK R[Rf i f this ADDRESS should be used for Legal Notification �.:: s- •c; 7, r ' <br /> OPERATOR INFORMATION & ADDRESS (Coeplete if Info►eation Different froe Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> P S - , <br /> E MAILING or STREET ADDRESS OPERATOR PHONE I UITM ANCA CODE <br /> R <br /> A <br /> T <br /> 0 CITY SfAIE IIP CODE <br /> k <br /> CHECE YElf if this ADDRESS should be used fay legal Notification <br /> PROPERTY OWNER INFORMATION t ADDRESS (Coeplete if Different froe Above) <br /> MAKE OWNER CONTACT NAME <br /> o <br /> 0 MAILING or STREET ADDRESS <br /> W OWNER PHONE I U11H AREA C000 <br /> (� <br /> R CITY STATE 11P CODE <br /> c <br /> CNEC�! HERE if this ADDRESS should be used for legal Notification <br /> Chtel A�tropriate lax <br /> T ACIIVE FARM TANK SITE (One or bore 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 /> C <br /> -Z—' PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site reeoved or closed in place) <br /> UNDER6ROUND TANK INFORMATION (List Additional tank inforeation on separate sheet if needed) <br /> T TANK Sl1E CHEMICALS STORED ESTIMATED DATE LAST USED METHOD Of CLOSURE DATE Of REMOVAL OR <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY If CUPRENTLY EMPTY If PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K bo o <br /> fl - <br /> a-- <br /> THIS <br /> 0THIS FORM HAS BEEN COMPLETED UNDER PENALTY Of PERJURY, AND TO THE BEST Of MY KNOWLEDGE, 1S TRUE AND CORRECT <br /> NAME f <br /> �� c�V G.iG����C/lC!yZ�• )(TLE � DATE . <br /> b{f Cf USf OXLY <br /> SWEEPS I COMP 1 LOC CODE DISI CODE 1 ACTIVE UGT I ETEMPT UGT I CLOSED UGT SWEEPS PRGMISUD CODE DATE <br /> I EH 73 041 (12/08) <br />