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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FARM TA14K,INFORMATION FORM <br /> FACILITY/SITE INFORMATION (Complete this Form for each facility/site) <br /> Ai) or BUSINESS NAME CONTACT NAME <br /> DDRESS (Street address of TANK location) PHONE # <br /> WITH AREA CODE <br /> I 17001 HASKELL LANE <br /> [TYTATE [IP CODE 4EAREST CROSS STREET <br /> ESCALON1`QA 95320 <br /> HECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION & ADDRESS (Complete if Information Different from Above) <br /> AMOPERATOR CONTACT NAME f <br /> I <br /> AILING or ST T 4DDRESS OPERATOR PHONE # WITH AREA CODE <br /> 17Y STATE IP CODE <br /> HECK "ERE if this ADDRESS should be used for Legal Notification <br /> PROPERTY OWNER INFORMATION & ADDRESS (Complete if Different from Above) <br /> AMS WNER CONTACT NAME <br /> AILING or ST 'T INFORMATION WNER PHONE # WITH AREA CODE <br /> ITY TATE �IP CODE <br /> 1C HECK_HERE if this ADDRESS should be used for Legal Notification <br /> Check Appropriate Sox <br /> �C CTIVE FARM TANK SITE (One or more underground TANKS > 11100 gal. capacity) <br /> �y XEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 ga(. capacity) <br /> ERMANENTLY 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 /> TANK S1ZE CHEMICALS STORED STIMATED DATE LAST USED MEHTOD OF CLOSURE DATE OF REMOVAL OR <br /> (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE REST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> AME �ITLE ATE <br /> OFFICE USE ONLY <br /> WEEPS # OMP # LOC CODE DIST CODE # ACTIVE UGT # EXPEMT UGT # CLOSED UGT SWEEPS PREM/SUB CODE DATE <br /> EH 23 044 10/89 <br />