REMOVAL_1989 - Laserfiche WebLink

Home Browse Search

Underground Stow Tank Program - Farm Taltformation Form FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) F FARM or BUSINESS NAME CONTACT NAME C ADDRESS(Street address of TANK location) PHONE# (with area code) I L I CITY STATE ZIP CODE NEAREST CROSS STREET T S c . o r4- 1 9sa0(0 o-, Y CHECK HERE if this ADDRESS should be used for Legal Notification OPERATOR INFORMATION&ADDRESS (Complete if information different from above.) 0 NAME OPERATOR CONTACT NAME P E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) R A T CITY STATE FilP CODE O R CHECK HERE is this ADDRESS should be used for Legal Notification. PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) NAME OWNER CONTACT NAME O NMAILING or STREET ADDRESS OWNER PHONE#(with area code) E R CITY STATE ZIP CODE CHECK HERE if this ADDRESS should be used for Legal Notification CHECK APPROPRIATE BOX .I, ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) Y P EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) E PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) UNDERGROUND TANK INFORMATION (List additional tank information on separate sheet If needed.) T TANK SIZE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OF REMOVAL OR A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE N K I N F O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. NAME TITLE O L DATE 7 , OFFICE USE ONLY SWEEPS# I COMP# I LOC CODE DIST CODE#ACTIVE IIGT I#EXEMPTUGT #CLOSEDUGT I SWEEPS PRGM/SUB CODE I DATE EH 23 044(12/88)