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Underground Storage Tank Program - Farm Tank Infonnc'tion Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F BUSINESS NAME CONTACTNAME <br /> A v ,t omL LG S�` I- . CLL G <br /> C ARP$PSS(Strut dress o TANK location) / I PHONE N (with area code) <br /> L //VAjEF f1� �Ld Zf _ (n -S <br /> I C STATE ZIP C06E NEAREST CROSS STREET <br /> T s(-0 lI ,., c Q � <br /> Y I CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete If Information different from above.) <br /> O NAME OPERATOR CONTACT NAME <br /> P <br /> E MAILING or SiREE ADDRESS OPERATOR PHONE N (with area code) <br /> R <br /> A <br /> T CITY STATE ZIP CODE <br /> 0 <br /> R I CHECK 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 /> o <br /> NMAILING o ADDRESS OWNER PHOdJEN(withareacode) <br /> E IAN 2 n 1", <br /> R CITY STATE ZIP CODE <br /> r.i J <br /> CHECK HERE if this ADDRESS should be used for Legal Notification " -`- <br /> CHECK APPROPRIATE BOX u� n <br /> .lX ACTIVE FARM TANK SITE yy-6D C t I,� ne or more undergrounddITCAN > 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 TANKSIZE CHEMICALS STORED ESTIMATED DATE LAST USED MEMOD OF CIASURE DATEOF REMOVAL Olt <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE IN PLACE <br /> N <br /> K <br /> I <br /> N <br /> F <br /> 10 1 <br /> THIS FORM IIAS=COMPLETED UNDER PENALTY OF 7RJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME <br /> ' -J_ ' <br /> a 1 C'J" R(_ f TITLE L DATE 273 �n <br /> OFFICE USE OAy <br /> SWGEPSN OOMPH IAC CODE DIST CODE NACDVE—Lr-7T # <br /> GT NNCIASED UGT SWEEPS PRGM/SUE CODE DATE <br /> EH 23 044(1 2J88) <br />