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Underground Store.se Tank Program - Farm Tank s<,formation Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> A L G k L= X114/L'C, T fj LL i Tom� <br /> C ADDRESS(Street address of TANK location) PHONE# (with area code) <br /> IIYYPT 5 /2 d. or109 ,s R-,3 y76 <br /> L <br /> I CITY STATE ZIP CODE NEAREST CROSS STREET <br /> T Pa/✓ � �� h �L�/� ���© �.i <br /> Y CHECK HERE if this ADDRESS should be used for Ugal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete if information different from above.) <br /> O NAME OPERATOR CONTACT NAME <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE# (with area code) <br /> R <br /> A <br /> T CITY STATE I ZIP CODE <br /> O <br /> RI ICHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION&ADDRESS (Complete if different from above.) <br /> NAME OWNER CONTACT NAME <br /> 0 <br /> NMAILING or STREET ADDRESS OWNER PHONE#(with area code) <br /> E <br /> R CITY STATE I ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> ,1, AC11VE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> E 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 SCORED ESTIMATED DATE VAST 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 /> N � 4 <br /> O / 1 <br /> TILS FORM HAS BEEN COMPLETED UNDER PENALTY OF PER URY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAMEi + ^✓� TITLE / .�/_tJ'�,.Qor� DATE <br /> OFFICE USE ONLY <br /> SWEEPS# COMP# LOC CODB DIST CODE#ACTIVE UGT #EXEMPT UGT #CLOSEDUGT SWEEPSPRG"UBCODE DATE <br /> EH 23 044(11/88) <br />